Every finding on record at Silver Heights Skilled Nursing and Rehabilitation

Based on observations and interviews, the facility failed to provide a comfortable and homelike environment for eight of 36 rooms. Specifically, the facility failed to provide residents with hand towels on a daily basis. Findings include: I. Facility policy and procedure The Homelike Environment policy and procedure, revised February 2021, was provided by the nursing home administrator (NHA) on 4/3/25 at 7:50 p.m. It read in pertinent part, Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. II. Observations On 3/31/25 the following observations were made: -At 1:45 p.m. room [ROOM NUMBER], a shared room, had no towels; and, -At 1:52 p.m. room [ROOM NUMBER], a shared room, had no towels. On 4/1/25 the following observations were made: -At 9:21 a.m. room [ROOM NUMBER], a shared room, had no towels; -At 9:21 a.m. room [ROOM NUMBER], a shared room, had no towels; -At 11:00 a.m. room [ROOM NUMBER], a shared room, had no towels;; -At 11:00 a.m. room [ROOM NUMBER], a shared room, had no towels; -At 11:00 a.m. room [ROOM NUMBER], a shared room, had no towels; and, -At 11:00 a.m. room [ROOM NUMBER], a shared room, had no towels. III. Resident interviews One of the residents who resided in room [ROOM NUMBER] was interviewed on 3/31/25 at 2:01 p.m. The resident said the facility did not provide him with towels. He said he had to use his own clothing to dry his hands due to the lack of towel availability. One of the residents who resided in room [ROOM NUMBER] was interviewed on 4/1/25 at 9:21 a.m. The resident said the facility did not provide him towels for his room. IV. Staff interviews The NHA and the director of nursing (DON) were interviewed together on 4/3/25 at 4:15 p.m. The DON said towels for residents were always available in the laundry room and the facility also kept towels in the shower rooms and linen closets. The DON said the certified nurse aides (CNA) were responsible for delivering the towels to the residents daily and replacing them as needed. The DON said the CNAs had previously received education regarding providing towels to residents daily. The DON said the facility would again provide education to ensure that staff consistently met this responsibility.

IV. Resident #10 A. Resident status Resident #10, age [AGE], was admitted on [DATE]. According to the April 2025 CPO, diagnoses included Alzheimer's disease and encephalopathy (brain dysfunction that includes mental status changes and memory issues). The 1/30/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of six out of 15. She required partial/moderate assistance with toileting and personal hygiene. She required supervision with transfers and was independent with eating and bed mobility. The MDS assessment indicated she had symptoms of little interest or pleasure in doing things for 12 to 14 days and felt down and depressed seven to 11 days over the assessment look back period. B. Record review Review of the April 2025 CPO revealed a physician's order for Sertraline 50 mg once a day, ordered 3/28/25. A review of the resident's EMR failed to reveal a psychotropic medication consent form for the use of the Sertraline or that the potential side effects of the medication were reviewed with the resident. C. Staff interview The NHA with the DON were interviewed together on 4/3/25 at 4:58 p.m. The NHA said the previous social worker, who was no longer at the facility, was responsible for ensuring consents for psychotropic medications were filled out and completed prior to starting the medication. The DON said the assistant director of nursing (ADON) was responsible for filling out the side effects on the consent. The NHA said since the social worker was no longer at the facility that was why psychotropic medication consents were not completed. The DON said she would take over the process. Based on record review and interviews, the facility failed to ensure three (#259, #15 and #10) of five residents reviewed out of 30 sample residents were free from unnecessary medications as possible. Specifically, the facility failed to: -Ensure the facility had proper justification for the implementation of an antipsychotic medication (Seroquel) for Resident #259; - Ensure Resident #15 or their responsible party was informed of the resident's use of Risperdal (antipsychotic) had black box warnings; -Ensure the ongoing use of Risperdal for Resident #15 was justified by consistent documented behaviors; and, -Ensure a consent was obtained for Resident #10's use of Sertraline (antidepressant). Findings include: I. Facility policy and procedure The Antipsychotic Medication Use policy and procedure, dated July 2022, was provided by the nursing home administrator (NHA) on 4/3/25 at 4:30 p.m. It revealed in pertinent part, Residents will not receive medications that are not clinically indicated to treat a specific condition. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, function, medical condition, specific symptoms, and risks to the resident. Diagnosis of a specific condition for which antipsychotic medications are necessary to treat will be based on a comprehensive assessment of the resident. Antipsychotic medications shall generally be used only for the following conditions: schizophrenia, schizoaffective disorder, schizophreniform disorder, delusional disorder, mood disorders, psychosis in absence of dementia, Tourette's Disorder, and Huntington Disease. Antipsychotic medications will not be used if the only symptoms are one or more of the following: wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, inattention or indifference to surroundings, sadness or crying alone that is not related to depression or other psychiatric disorders. II. Resident #259 A. Resident status Resident #259, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included Parkinson's disease, vascular dementia without behavioral disturbance, neurocognitive disorder with [NAME] bodies and major depressive disorder. The 1/17/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. He required maximum assistance of one person with showering, toileting, transfers and personal hygiene. The MDS assessment documented Resident #259 did not have hallucinations, delusions, or physical behavioral symptoms directed toward others during the assessment period. B. Record review The activities of daily living (ADL) care plan, initiated on 1/13/25, documented the resident had a self-performance deficit related to weakness, history of falling, dizziness, vascular dementia and Parkinson's disease. The interventions included working with hospice to ensure the resident maintained his current level of function, providing staff assistance of one person with bed mobility and transfers and moderate assistance with toileting. The fall care plan, initiated on 2/8/24 and revised on 3/31/25 (during the survey process), documented Resident #259 had a history of falls and an actual fall risk due to poor safety awareness, unsteady gait, poor comprehension and communication. The interventions included installing an anti-rollback device on his wheelchair (4/20/24), encouraging ground activities for stimulation and distraction (3/21/24), eyeballing the resident whenever going by to ensure he was not getting restless or did not require assistance (8/26/24), providing an activity basket/bag for engagement (9/25/24), providing a low bed and fall mat (2/19/24), conducting a therapy evaluation as needed (2/19/24) and conducting medication evaluation for restlessness and agitation by the resident's physician (3/12/25). -A review of Resident #259's comprehensive care plan did not reveal the resident had a history of behavioral concerns, episodes of restlessness or hallucinations. The 3/11/25 nursing progress note documented at 5:53 a.m. revealed Resident #259 was found in the hallway with his back against the floor, his legs extended out and his arms resting on his left and right side. Resident #259 was assessed by a registered nurse (RN) who observed a front right thigh skin tear and a small superficial scrape on his left elbow. The 3/11/25 hospice nursing progress note documented the resident had a fall the previous night with a skin tear to the left forearm and left hip. Staff reported the resident had hallucinations, however the resident did not report this himself. The resident said he was not aware of wakefulness or any hallucinations. The hospice nurse recommended adding Seroquel at night to attempt to assist in wandering and restlessness. The April 2025 CPO documented Resident #259 was started on Seroquel 50 milligrams (mg) at bedtime, ordered on 3/14/25. Cross reference F689 for failure to identify the root cause of Resident #259's falls and implement effective person-centered, non-pharmacological interventions. -A review of Resident #259's electronic medical record (EMR) on 4/2/25 did not reveal documentation the facility had identified the root cause of Resident #259's falls, nor attempted any non-pharmacological interventions prior to the initiation of Seroquel every night. The hospice nurse documented the facility staff had reported the resident as having hallucinations, however, there was no documentation in the resident's EMR to support that claim. The facility failed to document behaviors the resident exhibited other than getting up unassisted and sustaining a fall, nor any other justification for the antipsychotic intervention. C. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 4/3/25 at 1:45 p.m. CNA #1 said he thought Resident #259 had sustained recent falls because he wanted and needed to move. He said the facility staff kept the door open to Resident #259' a room as much as possible to keep an eye on him. He said he had worked at the facility for a long time and had not seen Resident #259 exhibit any behaviors or hallucinations. Registered nurse (RN) #1 was interviewed on 4/3/25 at 2:31 p.m. RN #1 said she was unaware Resident #259 had any behaviors nor hallucinations. RN #2 said Resident #259 was unable to transfer and get up without assistance. She said the facility staff followed the interventions in the folder to help residents prevent falls. RN #2 said Resident #259 had dementia, but she never witnessed the resident having any hallucinations or behaviors. The NHA and the director of nursing (DON) were interviewed on 4/3/25 at 4:18 p.m. The DON said she was not aware Resident #259 experienced any hallucinations or psychosis prior to or after the recent falls in March 2025. The NHA said the medication review was the intervention that was put into place following the resident's first fall on 3/11/25. The NHA said it was not the facility intention or process to immediately put a psychotropic medication into place. She said the facility should determine the root cause and put non-pharmacological interventions into place prior to the administration of a psychotropic medication. The DON said she was unable to find documentation of non-pharmacological interventions that were put into place following Resident #259's falls prior to the ordering and administration of Seroquel, an anti-psychotic medication. She said she was unable to find documentation of Resident #259 exhibiting restlessness or any other behaviors such as hallucinations. III. Resident #15 A. Resident status Resident #15, age [AGE], was admitted on [DATE]. According to the April 2025 CPO, diagnoses included dementia, Alzheimer's disease and cognitive communication deficit. The 1/16/25 MDS assessment revealed the resident had short-term and long-term memory impairment and required substantial assistance with decisions regarding tasks of daily life per staff assessment. The MDS assessment revealed the resident did not display physical behaviors directed towards others during the assessment period. B. Record review A review of Resident #15's April 2025 CPO revealed the following physician's order: Risperdal 0.5 mg, give 0.5 mg by mouth at bedtime for dementia with behaviors, ordered on 9/18/24. -The physician's orders and medication administration record (MAR) did not reveal documentation of a targeted behavior to monitor for the use of the Risperdal medication. -A review of Resident #15's EMR did not reveal documentation that the resident on their representative provided consent for the use of the Risperdal medication or that the provider or facility staff had discussed the black box warnings of the medication with the resident and/or resident representative to ensure they were fully informed of the potential risks for taking the medication. -Review of the physician progress notes revealed the resident exhibited only one episode of combative behaviors on 9/3/24. The facility initiated Risperdal on 9/19/24 for dementia with behaviors, however according to the MAR from September 2024 to March 2025, the resident did not display any combative behaviors other than one incident on 9/3/24 and one incident on 10/22/24. C. Staff interviews The DON and the NHA were interviewed on 4/3/25 at 4:15 p.m. The NHA said consent forms needed to be completed prior to administering the initial dose of any psychotropic medication. She said the social services department was responsible to ensure psychotropic consents were obtained prior to the administration of psychotropic medication. She said the facility was currently in the hiring process for a social worker. The DON said Resident #15 was admitted with multiple psychotropic medications which included Celexa (antidepressant), Seroquel (antipsychotic) and Ativan (anit-anxiety). The DON said the facility began making gradual dose reductions (GDR) and the Seroquel was discontinued in August 2024. She said by September, the resident exhibited increased agitation and combativeness, particularly with care. She said the behaviors were reported verbally and confirmed there was a lack of documentation showing Resident #15's behavior to justify the use of the Risperdal medication The DON said behavior tracking was completed by the nurses on the MAR. She said the CNAs completed behavior tracking documentation in the point of care (POC) system. The DON said consistent behavior tracking did not occurred for Resident #15's use of Risperdal.

Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in accordance with professional standards in one of one medication storage rooms. Specifically, the facility failed to ensure Tubersol (tuberculin purified protein derivative), Hepatitis B vaccine, Prevnar (pneumococcal vaccine), Fluzone (influenza vaccine), Spikevax (COVID-19 vaccine) and Basaglar insulin pens were stored within the appropriate medication storage refrigerator temperature guidelines. Findings include: I. Professional reference According to The Centers for Disease Control and Prevention (CDC) (3/29/24) Vaccine Storage and Handling Toolkit, retrieved on 4/8/25 from https://www.cdc.gov/vaccines/hcp/downloads/storage-handling-toolkit.pdf, If the cold chain is not properly maintained, vaccine potency may be lost, resulting in an unusable vaccine supply. According to the Sanofi Pasteur (2020) package insert for Tuberculin Purified Protein Derivative (Mantoux): Tubersol Food and Drug Administration (FDA), retrieved on 4/8/25 from www.fda.gov/media/74866/download, Store at 35 to 46 degrees Fahrenheit (F). According to the Merck Vaccine (2024) Storage and Handling of Recombivax B (Hepatitis B) guidelines, retrieved on 4/8/25 from https://www.merckvaccines.com/recombivax-hb/storage-handling/#:~:text=Storage%20and%20Handling%20for%20RECOMBIVAX%20HB%C2%AE%20[Hepatitis,DO%20NOT%20FREEZE%20since%20freezing%20destroys%20potency, Store vaccine vials and syringes at 36 to 46 degrees Fahrenheit; storage above or below the recommended temperature may reduce potency. According to the Moderna (2025) Spikevax (Covid 19) vaccine storage and handling guidelines, retrieved on 4/8/25 from https://products.modernatx.com/spikevaxpro/dosing-and-administration, Store frozen between -50 degrees F to 5 degrees F. Storage after thawing, store refrigerated between 36 degrees F to 46 degrees F for up to 60 days prior to use. According to the Pfizer (January 2025) Prevnar 20 Storage and Handling Guidelines, retrieved on 4/8/25 from https://prevnar20adult.pfizerpro.com/administration, Store refrigerated at 36 to 46 degrees F. According to the Sanofi Pasteur (July 2022) Fluzone Quadrivalent Influenza Vaccine Storage and Handling Guidelines, retrieved on 4/8/25 from https://www.fda.gov/media/119856/download, Store at 35 to 46 degrees F. According to Lilly (2024) Basaglar Insulin Pen Storage Guidelines, retrieved on 4/8/25 from https://insulins.lilly.com/basaglar, Before insulin use: When you get your unused pens, your insulin should be refrigerated at 36 degrees F to 46 degrees F. II. Facility policy and procedure The Medication Labeling and Storage policy and procedure, revised February 2023, was provided by the nursing home administrator (NHA) on 4/3/25 at 7:18 p.m. It read in pertinent part, If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. III. Observations On 4/3/25 at 1:25 p.m. the unit medication storage refrigerator was observed with the director of nursing (DON), who was also the facility's infection preventionist (IP). The medication storage refrigerator temperature was at 50 degrees F. -The medication storage refrigerator was not within the safe refrigerated medication storage temperature range of 36 degrees F to 46 degrees F The following items were found inside the medication storage refrigerator: -A vial of Tubersol; -A hepatitis B vaccine vial; -A Prevnar 20 vaccine vial; -A Fluzone influenza vaccine syringe; -A Spikevax vaccine syringe; and, -A Basaglar insulin pen. IV. Staff interview The DON was interviewed on 4/3/25 at 1:30 p.m. The DON said the medication storage refrigerator should be between 36 degrees F and 46 degrees F. She said the night shift nurses should check the refrigerator but there was no documentation that this was done. She said the facility did not have a refrigerator temperature log. She said she did not know how long the refrigerator had been above the safe storage temperature range. She said she would have the maintenance director (MTD) look at the refrigerator. The DON was interviewed a second time on 4/3/25 at 4:20 p.m. The DON said the MTD was going to order a new medication storage refrigerator, since the current refrigerator did not seem to be holding the correct temperature.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on three of three units. Specifically, the facility failed to: -Ensure hand hygiene was performed during wound care; -Ensure clean technique was followed during wound care; -Ensure residents' rooms were cleaned in a sanitary manner; -Ensure laundry was sorted in a sanitary manner; -Ensure laundry was washed in a different cycle for residents in isolation; and, -Ensure residents' personal items were labeled and stored in a sanitary manner. Findings include: I. Facility policy and procedure The Infection Prevention and Control Program (IPCP) and Plan, revised October 2018, was provided by the nursing home administrator (NHA) on 3/31/25 at 1:10 p.m. It revealed in pertinent part, An IPCP is established and maintained to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infections. The program is based on accepted national infection prevention and control standards. II. Failed to ensure hand hygiene and clean technique was followed during wound care A. Professional references According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene for Healthcare Workers, updated 2/27/24, retrieved on 4/8/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, Know when to clean your hands: immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids, or contaminated surfaces and immediately after glove removal. Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings, always clean your hands after removing gloves, remember to remove gloves carefully to prevent hand contamination as dirty gloves can soil your hands. B. Observations On 4/2/25 at 1:15 p.m. the director of nursing (DON), who was also the facility's infection preventionist (IP), and the wound care physician entered Resident #40's room to perform wound care for the resident on his left foot. The following observations were made: The DON performed hand hygiene and donned a gown and a pair gloves upon entering the resident's room. The DON brought in wound dressing supplies and placed them on the resident's bedside table. The DON then removed the heel boot on Resident #40's left foot. The DON removed the old dressing on Resident #40's left lateral foot. The DON placed the old dressing on the bed. The DON placed a disposable underpad on the bed under the resident's left foot, on top of the old dressing. The DON then used a clean gauze and an individual saline solution vial to wipe the wound. The DON disposed of the gauze and saline solution. The DON opened the resident's clean dressing from the bedside table and applied the dressing. -Throughout the wound care process, the DON failed to establish and maintain a clean field for the resident's clean wound supplies. -Additionally, the DON failed to perform hand hygiene and change gloves after touching the old soiled wound dressing and before touching the clean wound supplies and applying a new dressing to the resident's left foot wound. On 4/2/25 at 1:30 p.m. the DON and the wound care physician entered Resident #33's room to perform wound care for the resident. The following observations were made: The DON removed clean dressing supplies from the wound care cart. The DON donned gloves and a gown. The DON placed the clean wound care supplies on Resident 33's wheelchair at the end of the bed. The DON removed the resident's left heel boot. The DON picked up the betadine pain stick and painted the resident's left heel with betadine. The DON then obtained saline and clean gauze and removed the soiled dressing from the resident's sacral wound. She cleaned the sacral wound and applied a clean dressing. The DON then removed her gown and gloves and disposed of the soiled dressing supplies in the trash. -Throughout the wound care process, the DON failed to establish and maintain a clean field for the resident's clean wound supplies. -The DON failed to perform hand hygiene before donning gloves and a gown. -Additionally, the DON failed to perform hand hygiene and change gloves after cleaning the resident's left heel wound and before proceeding to the resident's sacral wound. -The DON failed to change her gloves and perform hand hygiene after removing Resident #33's soiled sacral wound dressing and before cleaning the wound and applying a new dressing. On 4/2/25 at 1:45 p.m. the DON and the wound care physician entered Resident #20's room to perform wound care for the resident. The following observations were made: The DON removed clean dressing supplies from the wound cart. The DON donned gloves and a gown. The DON pulled back the resident's incontinence briefs and removed the old soiled dressing from the resident's sacral wound. The DON opened clean wound care supplies and applied silver alginate (an antibacterial wound treatment) and a border dressing. The DON removed her gown and gloves and disposed of everything in the trash. -Throughout the wound care process, the DON failed to establish and maintain a clean field for the resident's clean wound supplies. -The DON failed to perform hand hygiene before donning gloves and a gown. -Additionally, the DON failed to perform hand hygiene and change gloves after removing the resident's old wound dressing and before touching the resident's clean dressing supplies. C. Staff interviews The DON was interviewed on 4/2/25 at 2:52 p.m. The DON said before performing wound care, a clean field should be established. She said a bedside table or designated surface should be wiped down with the Super Sani Cloth germicidal and disinfectant wipes. She said this should be done before placing any clean dressing supplies on top of the surface. She said hand hygiene should be done before putting on gloves and a gown. She said hand hygiene should be performed and gloves should be changed after touching a dirty area and before touching clean wound supplies. III. Failed to ensure resident's rooms were cleaned in a sanitary manner A. Professional reference The Centers for Disease Control (CDC) Environment Cleaning Procedures (3/19/24), was retrieved on 4/8/25 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part, Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Clean resident areas before cleaning resident toilets. Include identified high touch surfaces and items in checklists and other job aids to facilitate completing cleaning procedures. Proceed in a systematic manner to avoid missing areas. In a multi-bed area, clean each resident zone in the same manner. For higher risk areas, change cleaning cloths between each resident zone (use a new cleaning cloth for each resident bed). B. Facility policy and procedure The Daily Room Cleaning Procedures policy and procedure, undated, was provided by the NHA on 4/3/25 at 7:18 p.m. It revealed in pertinent part, Always start with cleaning the resident's restroom. Disinfect toilet bowls and urinals. C. Manufacturer's recommendations The Diffense Cleaner and Disinfectant manufacturer guidelines, 2025, was retrieved on 4/8/25 from https://www.sfreedman.com/products/1024-spartan-rtu-diffense-clnr-quart/525039070/?srsltid=AfmBOoo7j5wqpwdbMMjm1Fj0oNYH2ChUBkqNjJgQ6mERSEMaPhUfyA2Z. It read in pertinent part, Effective against a comprehensive range of harmful bacteria and viruses and less than one minute disinfection. D. Observations On 4/3/25 at 8:53 a.m. housekeeper (HK) #1 was observed cleaning a shared room [ROOM NUMBER]. HK #1 put on gloves and obtained a disinfectant-saturated rag from the housekeeping cart and wiped the bedside table on the A side of the room. She then wiped down the window sill and the bedside table on the B side of the room. After wiping both residents' bedside tables and the windowsill with the same rag, she disposed of the rag. She then mopped the entire room, starting from the far side of room (the B side), mopping under both beds and mopped her way to the door. After finishing the mopping, HK #1 disposed of the mop head and swept up the debris. -HK #1 failed to clean the resident's area on the B side of the room separately from the resident's area on the A side of the room. -HK #1 failed to change gloves, perform hand hygiene or change rags before proceeding from the A side to the B side of the room. -HK #1 failed to change mop heads after mopping the B side of the room before mopping the A side of the room. -HK #1 failed to clean the high touch areas in the room, including light switches and door knobs. E. Staff interview The maintenance director (MTD), who was also the housekeeping supervisor, was interviewed on 4/3/25 at 9:20 a.m. The MTD said HK #1 should not be interviewed because she was new to the position and because of the language barrier. He said the cleaner/disinfectant the facility used had a one-minute disinfection time. He said residents' rooms were cleaned starting from high areas to low areas. He said high touch areas, such as light switches and door handles should be included when the rooms were cleaned. IV. Failed to ensure laundry was sorted in a sanitary manner and laundry was washed in a different cycle for residents on isolation precautions A. Professional reference According to the CDC's Appendix D-Linen and Laundry Management (3/19/24), retrieved on 4/9/25 at 2:04 p.m. from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-d.html, Use hot water 70 degrees Celsius (C) to 80 degrees C for 10 minutes or 158 degrees Fahrenheit (F) to 176 degrees F and an approved laundry detergent. Use disinfectant on a case by case basis, depending on the origin of the soiled linen (for example, linens from an area on contact precautions). B. Facility policy and procedure The Departmental (Environmental Service) Laundry and Linen policy and procedure, revised January 2014, was provided by the NHA on 4/3/25 at 7:50. It read in pertinent part, Consider all soiled linen to be potentially infectious and handle with standard precautions. Laundry for high temperature processing, wash linen in water that is at least 160 degrees F for a minimum of 25 minutes. C. Observations and staff interview On 4/3/25 at 9:42 a.m. the laundry area was observed with the MTD, the NHA and the laundry aide (LA). The laundry area was entered through the clean sorting room. The MTD explained the laundry process. The door opening where the laundry carts were sent for dirty laundry had a door leading to the soiled laundry sorting room. Upon entering the sorting room, the LA said she put on a gown first prior to sorting the laundry. Multiple cloth long sleeve gowns were observed hanging on hooks behind the laundry sorting room door. The reusable gowns were overlaying each other and touching other gowns. The LA said she washed the reusable protective gowns maybe once a week, but not after each use. The LA said she did not know of any potential infection control issues with that practice. The MTD said not washing the gowns after each use created the potential for cross contamination. The MTD said he would get the laundry staff more gowns to use and dispose of after each time they sorted the soiled laundry items. The LA said she would put on gloves and use a tie to close the sleeves of the gown at her wrist because the gown sleeves were too long. The LA pointed to three black hair ties hanging on the wall with a thumb tack. The LA said she used the hair ties all of the time and did not clean them after use. The NHA said the hair ties were not cleanable and should not be used. The MTD said it was possible for the debris from the soiled clothing and linen to be transferred to the hair ties. V. Failed to ensure residents' personal items were labeled and stored in a sanitary manner A. Observations On 3/31/25 the following observations were made: -At 1:45 p.m. room [ROOM NUMBER], a shared room, had on the vanity below the mirror two unlabeled toothbrushes, one unlabeled container of Listerine and one unlabeled deodorant; and, -At 1:52 p.m. room [ROOM NUMBER], a shared room, had on the vanity below the mirror two unlabeled toothbrushes. On 4/1/25 the following observations were made: -At 9:21 a.m. room [ROOM NUMBER], a shared room, had on the vanity below the mirror two unlabeled toothbrushes; -At 11:00 a.m. room [ROOM NUMBER], a shared room, had on the vanity one unlabeled toothbrush; -At 11:02 a.m. room [ROOM NUMBER], a shared room, had two unlabeled toothbrushes on the vanity; -At 11:03 a.m. room [ROOM NUMBER], a shared room, had a cup with one unlabeled toothbrush sitting on the vanity; and, -At 11:05 a.m. room [ROOM NUMBER], a shared room, had a cup which contained two unlabeled toothbrushes. B. Staff interview The DON and the NHA were interviewed together on 4/3/25 at 4:15 p.m. The DON said she was responsible for ensuring that residents' toothbrushes were labeled and stored in a sanitary manner. She said in the past, the facility had used special covers for the toothbrushes and had labeled them. She said over time, the special toothbrush covers had been thrown away. She said she would get new covers for the toothbrushes and ensure they were labeled for each specific resident.

Based on observations, record review and interviews, the facility failed to ensure one (#12) of one resident with limited range of motion received appropriate treatment and services out of 30 sample residents. Specifically, the facility failed to: -Develop a comprehensive care plan for Resident #12's left hand contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints); and, -Ensure Resident #12 was provided the recommended preventive measures for contracture management of her left hand. Findings include: I. Facility policy and procedure The Resident Mobility and Range of Motion policy and procedure, dated July 2017, was provided by the nursing home administrator (NHA) on 4/3/25 at 4:30 p.m. It revealed in pertinent part, Residents will not experience an avoidable reduction in range of motion (ROM), residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM, residents with limited mobility will receive appropriate services, and equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. The care plan will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts, and the care plan will include the type, frequency, and duration of interventions, as well as measurable goals and objectives. The resident and representative will be included in determining these goals and objectives. II. Resident #12 A. Resident status Resident #12, age 66, was admitted on [DATE] and readmitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included left hemiplegia (paralysis on one side of the body) following cerebral infarction and a contracture of the left hand. The 2/20/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required maximum assistance with transfers and bed mobility and moderate assistance for bathing, toileting, dressing and personal hygiene. The MDS assessment indicated Resident #12 was part of the range of motion program, which included passive range of motion and splint or brace assistance. It indicated the resident had had zero days of therapy during the seven-day look-back assessment review period. B. Resident interview and observations Resident #12 was interviewed on 4/1/25 at 10:02 a.m. Resident #12 said her left hand was contracted due to a previous stroke. She said the facility did not provide her with any therapy services, braces or other preventative measures for her left hand contracture. Resident #12's left hand was contracted with her wrist and four fingers flexed and her thumb extended against the other fingers. The resident did not have a brace or other devices on her left hand to help prevent the contracture from worsening or causing skin breakdown on her hand. On 4/2/25 at 3:20 p.m. Resident #12 was in bed. Her left hand was contracted and she was not wearing a palm guard or brace on her hand. On 4/3/25 at 11:22 a.m. Resident #12 was in bed. Her left hand was contracted and she was not wearing a palm guard or any other device on her hand. C. Record review Review of the 4/20/23 occupational therapy (OT) plan of treatment for Resident #12 documented the OT recommended wearing a palm guard on her left hand for up to eight hours every day. A review of Resident #12's electronic medical record (EMR) did not reveal documentation that Resident #12 was placed on a program to wear a palm guard for eight hours per day, which was the recommendation of the occupational therapist. -Review of Resident #12's comprehensive care plan failed to reveal a care plan focus for Resident #12's left hand contracture or any documented preventative measures and interventions. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 4/3/25 at 2:14 p.m. CNA #1 said Resident #12 had difficulty with her left hand due to paralysis. He said he thought she had used a device for her hand, but he said he had not seen it in over a month. He said Resident #12 was unable to move her left hand, so he helped her clean her hand. Registered nurse (RN) #1 was interviewed on 4/3/25 at 2:31 p.m. RN #1 said she was unaware of Resident #12's left hand contracture or any preventative measures put in place for the contracture. The director of rehabilitation (DOR) was interviewed on 4/3/25 at 3:16 p.m. The DOR said each therapist provided verbal training for any ongoing programs for contracture management after therapy had completed the residents' treatment plans. She said the facility did not have a formal way of tracking the contracture management program to ensure staff were following the therapists' recommendations. She said it was important the therapists' recommendations were followed to ensure residents' contracture did not worsen. The DOR said the occupational therapist recommended Resident #12 be provided a palm protector which should be worn eight hours per day. She said she was not sure if that recommendation was being followed. She said she would reassess Resident #12 to ensure her contracture had not worsened and provide additional education to the staff regarding the recommendations. -The facility did not provide documentation of Resident #12's initial contracture measurements prior to the survey exit to see if the resident's contracture had worsened. The NHA and the director of nursing (DON) were interviewed together on 4/3/25 at 4:18 p.m. The DON said the facility had several residents who required a contracture management program. She said the contractures should be identified in the comprehensive care plan with the preventative measures. She said the preventative measures should be identified in the CNA documentation system to ensure the CNAs provided the care that was recommended by the occupational therapist. The NHA confirmed Resident #12 had a left hand contracture. She said the resident's contracture was not identified in the comprehensive care plan and the palm protector recommendation was not part of the care documented for Resident #12. The NHA said the facility did not have a tracking system in place to ensure residents were receiving the preventative measures of their recommended contracture management program.

Based on record review and interviews, the facility failed to ensure one (#259) of three residents reviewed for accidents out of 30 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to identify the root cause of Resident #259's falls and implement effective person-centered interventions. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, dated June 2022, was provided by the nursing home administrator (NHA) on 4/3/25 at 4:30 p.m. It revealed in pertinent part, A fall is defined as unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force, such as a resident pushing another resident, whether the event was witnessed or unwitnessed. The facility assists each resident in maintaining his or her highest practicable level of function by providing the resident adequate supervision, assistive devices and functional programs, as appropriate, to minimize the risk for falls. When a resident is found on the floor, the facility is obligated to investigate to determine how the resident got there and put into place an intervention to minimize it from recurring. Unless there is evidence suggesting otherwise, the most logical conclusion is that a fall has occurred. The IDT (interdisciplinary team) designee will discuss recommended significant changes to the care plan to minimize repeat falls with the resident and/or resident's representative. The care plan will be reviewed as indicated. II. Resident #259 A. Resident status Resident #259, age 76, was admitted on [DATE] and readmitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included Parkinson's disease, vascular dementia without behavioral disturbance, neurocognitive disorder with [NAME] bodies, major depressive disorder and moderate protein-calorie malnutrition. The 11/29/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. He required maximum assistance of one person with showering, toileting, transfers and personal hygiene. The MDS assessment documented Resident #259 did not have hallucinations, delusions or physical behavioral symptoms directed toward others during the assessment period. B. Record review The activities of daily living (ADL) care plan, initiated and revised on 1/13/25, documented the resident had a self-performance deficit related to weakness, history of falling, dizziness, vascular dementia and Parkinson's disease. The interventions included working with hospice to ensure the resident maintained his current level of function, providing staff assistance of one person with bed mobility and transfers and moderate assistance with toileting. The fall care plan, initiated 2/8/24 and revised 3/31/25 (during the survey process), documented Resident #259 had a history of falls and an actual fall risk due to poor safety awareness, unsteady gait, poor comprehension and communication. The interventions included installing an anti-rollback device on his wheelchair (4/20/24), encouraging ground activities for stimulation and distraction (3/21/24), eyeballing the resident whenever going by to ensure he was not getting restless or did not require assistance (8/26/24), providing an activity basket/bag for engagement (9/25/24), providing a low bed and fall mat (2/19/24), therapy evaluation as needed (2/19/24) and conducting medication evaluation for restlessness and agitation by the resident's physician (3/12/25). The 1/2/25 physician's progress note documented Resident #259 was seen while sitting in the dining area, alert and in no distress, however he appeared quite weak. The facility staff had not reported any new issues or problems. The 3/11/25 nursing progress note, documented at 5:53 a.m., revealed Resident #259 was found in the hallway with his back against the floor, his legs extended out and his arms resting on his left and right side. Resident #259 was assessed by a registered nurse (RN) who observed a front right thigh skin tear and a small superficial scrape on his left elbow. -Review of Resident #259's care plan and electronic medical record (EMR) did not reveal any immediate interventions put into place after the resident's 3/11/25 sustained fall with injuries. The 3/11/25 hospice nursing progress note documented Resident #259 had a fall the previous night with a skin tear to the left forearm and left hip. Staff reported the resident had hallucinations, however, the resident did not report this himself. The resident said he was not aware of wakefulness or any hallucinations. The hospice nurse recommended adding Seroquel at night to attempt to assist with Resident #259's wandering and restlessness. -However, a review of the resident's EMR did not indicate episodes of restlessness or agitation until after the falls occurred. Cross reference F758 for failure to ensure there was adequate justification prior to the prescription and administration of a psychotropic medication for Resident #259. The 3/12/25 physician's progress note documented the physician saw Resident #259 in the hallway and he was confused and pleasant, ambulatory and seemed fairly steady. However the resident had a fall with some skin tears the night before last. It indicated the staff were not reporting any other issues. The 3/13/25 progress note, documented at 6:04 p.m., revealed Resident #259 was found in the hallway, lying down on the floor. The resident was not able to state what happened. A hematoma (bruise) was observed on the left side of his forehead and he had small skin tears on both hands. The facility contacted Resident #259's physician to evaluate medications for restlessness and agitation. The 3/13/25 IDT review documented Resident #259 had an unwitnessed fall and was found in the hallway, lying down. The resident was unable to give a statement about what happened. The intervention included the physician was to review all medications for restlessness and agitation. -However, a review of the resident's EMR did not indicate episodes of restlessness or agitation until after the falls occurred. The 3/14/25 nurse practitioner progress note documented Resident #259 had a fall on the evening of 3/13/25 resulting in a large hematoma to his left forehead and eye. Hospice suggested Seroquel nightly. The 3/16/25 nursing progress note, documented at 11:55 p.m., revealed Resident #259 was observed in the hallway, lying on the floor beside his wheelchair. The resident reported a skin tear to his right forearm and was assisted back to the wheelchair by two staff members. The resident was taken to the nursing station to watch television and be supervised by staff. The 3/20/25 IDT review documented the resident sustained two falls. The recommendation was for hospice to come and evaluate the resident for noted increased restlessness and agitation. Hospice started the resident on Seroquel 50 milligram (mg) at night. -However, a review of the resident's EMR did not indicate episodes of restlessness or agitation until after the falls occurred. -A review of the resident's EMR on 4/2/25 did not reveal documentation that the facility had identified the root cause of Resident #259's restlessness, there were not any non-pharmacological interventions put into place by the facility and there was no documentation or care plan to indicate the resident had any hallucinations or behavioral concerns to justify the immediate use of the Seroquel following Resident #259's falls. III. Staff interviews Certified nurse aide (CNA) #1 was interviewed on 4/3/25 at 1:45 p.m. CNA #1 said Resident #259 required maximum assistance with transfers because he was unable to hold his balance. CNA #1 said Resident #259 was unable to get up by himself most of the time, but a few times he was able to get up without assistance. CNA #1 said he thought Resident #259 had sustained recent falls because he wanted and needed to move. He said the facility staff kept the door open to Resident #259's room as much as possible to keep an eye on him. Registered nurse (RN) #1 was interviewed on 4/3/25 at 2:31 p.m. RN #1 said she was unaware Resident #259 had sustained any recent falls. She said she was an agency nurse. She said she had not been informed Resident #259 was a fall risk. RN #1 said Resident #259 had dementia, but she never witnessed the resident having any hallucinations or behaviors. She said she was unaware of the fall interventions for Resident #259. The NHA and the director of nursing (DON) were interviewed together on 4/3/25 at 4:18 p.m. The DON said she was not aware of Resident #259 having any hallucinations or psychosis prior to or after the recent falls. She said she was unable to find documentation of non-pharmacological interventions that were put in place following the falls and prior to the ordering and administration of Seroquel, an anti-psychotic medication. She said she was not sure why Resident #259 was up early in the morning or late at night, but she would have guessed it was because of the progression of his disease. She said she was unable to find documentation that the facility had determined the root cause of the resident's restlessness of getting up without assistance.

Based on record review and interviews, the facility failed to assist residents to obtain routine or emergency dental services, as needed, for one (#12) of one resident reviewed for ancillary services out of 30 sample residents. Specifically, the facility failed to ensure a dental referral was followed upon timely for Resident #12. Findings include: I. Facility policy and procedure The Resident Dental Services policy and procedure, dated December 2016, was provided by the nursing home administrator (NHA) on 4/3/25 at 4:30 p.m. It revealed in pertinent part, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services are provided to our residents through a contract agreement with a licensed dentist that comes to the facility monthly, referral to the resident's personal dentist, referral to community dentists, or referral to other health care organizations that provide dental services. Social services representatives will assist residents with appointments, transportation, arrangements, and for reimbursement of dental services under the state plan, if eligible. Direct care staff will assist residents with denture care, including removing, cleaning, and storing dentures. If dentures are damaged or lost, residents will be referred for dental services within three days. If the referral is not made within three days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services and the reason for the delay. II. Resident #12 A. Resident status Resident #12, age 66, was admitted on [DATE] and readmitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included bipolar disorder, left hemiplegia (paralysis on one side of the body) following cerebral infarction, major depressive disorder and post-traumatic stress disorder. The 2/20/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required maximum assistance with transfers and bed mobility and moderate assistance for bathing, toileting, dressing and personal hygiene. B. Resident interview Resident #12 was interviewed on 4/1/25 at 9:55 a.m. Resident #12 said she had had pain in her bottom jaw for a long time now. She said she saw the dentist at the facility quite a few months prior and was still waiting for another appointment. She said she had not received any communication from the facility on when her dental appointment would be. Resident #12 said she was having pain, but was still able to eat. C. Record review The 4/24/24 dental progress note revealed Resident #12 presented with soreness in the lower jaw. The 11/13/24 dental progress note revealed Resident#12 was seen for treatment due to soreness in the lower jaw and indicated the resident experienced tenderness to the lower ridge. The dentist documented a referral for the resident to have an alveoloplasty (a surgical procedure where the jawbone is reshaped and smoothed, particularly after tooth extraction, to prepare for dentures or dental implants) of her lower ridge (alveolar ridge located just below the bottom teeth). A review of Resident #12's electronic medical record (EMR) did not reveal documentation the facility had followed up on the dental referral from 11/13/24. III. Staff interviews The NHA was interviewed on 4/3/25 at 1:42 p.m. The NHA said the social services department was responsible for the coordination of all ancillary services, including dental care. She said the facility was currently in the process of hiring social services staff. The NHA said she was unable to find documentation that the dental referral had been made for Resident #12, based on the dentist's recommendation from November 2024. She said she would contact the dentist to determine where Resident #12 should be sent for the procedure.

Based on record review and interviews, the facility failed to ensure two (#15 and #42) of five residents out of 30 sample residents were kept free from abuse. Specifically, the facility failed to: -Ensure Resident #15 was kept free from physical abuse by Resident #13; and, -Ensure Resident #42 was kept free from physical abuse by Resident #58. Findings include: I. Incident of physical abuse between Resident #13 and Resident #15 on 1/15/25 A. Facility investigation The 1/15/25 facility abuse investigation, documented at 2:00 p.m., revealed that Resident #13 was ambulating with his front wheel walker when Resident #15, who was seated, reached out and touched or grabbed Resident #13's left wrist. Resident #13 asked Resident #15 to let go. When Resident #15 did not let go, Resident #13 grabbed Resident #15 by the back of his neck, shook him and told him not to touch him. The staffing coordinator (SC) witnessed the incident. The SC immediately separated the residents and reported the incident to the nursing home administrator (NHA). The director of nursing (DON) assessed Resident #15's neck and observed no injury. The investigation documented Resident #15 had severe dementia and would reach out and grab things and people at times. Resident #13 was interviewed by the NHA and the DON following the incident. Resident #13 said, Oh sure, he would say that when told the incident had been reported. When the staff explained that someone else witnessed the incident, Resident #13 said, I was walking by and he grabbed my arm. I don't like that, so I grabbed his neck. The investigation documented the SC provided a written witness statement. The SC said she was coming out of her office when she saw Resident #15 in his doorway and Resident #13 was walking by. She said Resident #15 reached out and grabbed Resident #13's left wrist. She said Resident #13 shouted, Don't touch me and then grabbed Resident #15 by the neck and shook him with his right hand. The SC said she went over and separated them. She said when she separated the residents, Resident #15 struck her. The SC said Resident #13 responded, He grabbed me and I don't like that. The investigation documented the facility determined Resident #13 did shake the neck of Resident #15. The intervention included having the activities department and therapy assess different items Resident #15 could hold to help decrease his reaching out, as he was very tactile at that time. Resident #13 was educated to walk away or ask for help in these situations and that grabbing and shaking people was not acceptable. The facility added physical aggression to Resident #13's care plan. The investigation concluded the abuse was substantiated as the action by Resident #13 was willful. B. Resident #15 - victim 1. Resident status Resident #15, age 83, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included dementia, Alzheimer's disease and cognitive communication deficit. The 1/16/25 minimum data set (MDS) assessment revealed the resident had short-term and long-term memory impairment and required substantial assistance with decisions regarding tasks of daily life, per staff assessment. The MDS assessment revealed the resident did not display physical behaviors directed towards others during the assessment period. 2. Record review The behavioral care plan, initiated 8/5/23 and revised 1/27/25, documented Resident #15 had a history of involvement in physical altercations with other residents, both received and initiated. It indicated Resident #15 had impaired cognitive functioning and impaired thought processes related to dementia and struck out if startled and became agitated if overstimulated. Pertinent interventions included monitoring and recording the occurrence of target behavior symptoms such as pacing, wandering, disrobing, inappropriate responses to verbal communication, and violence or aggression toward staff or others and taking the resident to a quieter area and away from other residents if he became agitated due to overstimulation. C. Resident #13 - assailant 1. Resident status Resident #13, age 75, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included Parkinson's disease (a disease that causes involuntary movements). The 1/12/25 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident required partial to moderate assistance from one staff member with toileting, dressing and personal hygiene. 2. Record review The behavioral care plan, initiated 8/13/24 and revised 1/21/25, documented the resident had a history of episodes of declining medications and care despite education. It documented the resident exhibited unprovoked verbally and physically aggressive behavior toward others at times. Pertinent interventions included assisting the resident to develop more appropriate methods of coping and interacting, encouraging the resident to express his needs and feelings appropriately, explaining and reinforcing to the resident why the behavior was inappropriate or unacceptable, intervening as necessary to protect the rights and safety of others, approaching and speaking to the resident in a calm manner, diverting the resident's attention, removing the resident from the situation and taking the resident to an alternate location as needed. II. Incident of physical abuse between Resident #42 and Resident #58 on 12/28/24 A. Facility investigation The 12/28/24 facility abuse investigation, documented at 6:58 p.m., revealed Resident #42 and Resident #58 were in the television common room when they began loudly arguing and yelling at one another. Resident #42 told Resident #58 to shut up and go away. Resident #58 attempted to push Resident #42's wheelchair, but instead pushed the resident directly, causing him to fall from the wheelchair onto the floor. Resident #42 landed on his right side and sustained two small skin tears to his right forearm. Staff immediately separated the residents and returned each resident to their respective room. Resident #42 was assessed by the registered nurse (RN) on duty, who provided first aid treatment to the skin tears that were sustained to the right forearm. Resident #42 later developed bruising to his right hip and buttock area. The facility notified the physician, the family members, the DON, the NHA, the police and the ombudsman. Resident #42 was upset, but reported he was not afraid of Resident #58. Resident #58 said he was trying to push Resident #42's wheelchair away and did not realize his strength. Resident #58 had a history of verbal aggression toward staff when told he could not go home but typically calmed when reminded he was staying at the facility short-term before moving to his son's house. The facility substantiated the physical abuse of Resident #42 by Resident #58, which resulted in two skin tears. B. Resident #42 - victim 1. Resident status Resident #42, age 80, was admitted on [DATE]. According to the April 2025 CPO, diagnoses included weakness, abrasion of lower back and cognitive communication deficit. The 12/21/24 MDS revealed the resident had moderate cognitive impairments with a BIMS score of 11 out of 15. The resident required partial to moderate assistance from one staff member with showers. The MDS assessment documented the resident did not display physical behaviors directed towards others during the assessment period. 2. Record review The 1/2/25 head-to-toe skin assessment revealed the resident had existing bruises on the right hip and buttock. The assessment also revealed an existing skin tear on the right forearm, which was covered with a dry dressing and showed no signs or symptoms of infection. C. Resident #58 - assailant 1. Resident status Resident #58, age 78, was admitted on [DATE] and discharged on [DATE]. According to the January 2025 CPO, diagnoses included dementia with other behavioral disturbances, multiple sclerosis and hearing loss. The 1/22/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 11 out of 15. The resident required substantial assistance with oral hygiene, dressing, transferring, and toileting. The MDS assessment indicated the resident had verbal behaviors directed towards others. III. Staff interviews The DON and the NHA were interviewed on 4/3/25 at 4:15 p.m. The NHA said that as soon as an abuse situation was identified, the staff should separate the residents to ensure their safety. She said the facility staff should immediately notify the NHA and the DON so that the investigation could begin promptly. The DON said Resident #15, who often reached out toward others, grabbed Resident #13's arm as Resident #13 passed by. The DON said Resident #13 asked Resident #15 not to touch him. The DON said when Resident #15 did not respond appropriately, Resident #13 grabbed Resident #15 by the back of his neck. She said Resident #13 later admitted he should not have reacted that way. The NHA said the facility substantiated physical abuse by Resident #13 toward Resident #15. She said Resident #13 was willful in his actions. The NHA said Resident #58 was at the facility for a short respite stay. The DON said Resident #58 and Resident #42 got into a verbal altercation in the common room and Resident #42 told Resident #58 to shut up and go away. The DON said Resident #58 attempted to push Resident #42's wheelchair but instead pushed Resident #42, causing him to slide out of his chair and sustain two skin tears to his right arm. The DON said that Resident #58 admitted to pushing Resident #42 out of his chair. The DON said the incident was substantiated as Resident #58 was willful in his actions.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities for one (#24) of three residents out of 30 sample residents. Specifically, the facility failed to provide timely toileting assistance or incontinence care for Resident #24. Findings include: I. Resident #24 A. Resident status Resident #24, age 77, was admitted on [DATE]. According to the April 2025 computerized physician orders (CPO), diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body), cognitive communication deficit and unsteadiness on feet. The 2/27/25 minimum data set (MDS) assessment revealed the resident had severe impairment in making decisions regarding tasks of daily life, per the staff assessment for mental status. He required substantial assistance with oral care, personal hygiene, toileting, bathing, dressing and transferring. B. Observations During a continuous observation on 4/1/25, beginning at 1:08 p.m. and ending at 4:50 p.m., the following was observed: At 1:08 p.m. Resident #24 was lying on the bed in his room, sleeping. At 1:13 p.m. an unidentified staff member entered the resident's room and removed his lunch tray. At 4:16 p.m. two unidentified staff members entered Resident #24's room. The staff members asked if Resident #24 wanted the television turned on and if he preferred the window to be closed. The staff members turned on the television and exited the room. -Staff did not check Resident #24 for incontinence or provide toileting assistance to the resident during the nearly four hour continuous observation. During a continuous observation on 4/2/25, beginning at 8:25 a.m. and ending at 2:10 p.m., the following was observed: At 8:25 a.m. Resident #24 was eating breakfast in the dining room. At 9:00 a.m. the resident was taken from the dining room to the common area to watch television, with a pillow on his lap and his right arm resting on the pillow. At 9:22 a.m. an unidentified staff member wheeled Resident #24 to the indoor gardening activity. -Resident #24 was not checked for incontinence or offered any toileting assistance prior to being taken to the activity. At 11:54 a.m. an unidentified staff member wheeled Resident #24 to the chapel for lunch. -The resident was not checked for incontinence or offered toileting assistance prior to being taken to lunch. At 12:40 p.m. Resident #24 finished eating lunch and was wheeled to his room by certified nurse aide (CNA) #1 and assisted to bed. -CNA #1 did not check the resident for incontinence or offer toileting assistance after lunch. At 12:45 p.m. Resident #24 was sleeping in bed. At 2:02 p.m. Resident #24's skin was observed with CNA #1. CNA #1 said Resident #24 was soiled with urine and had a bowel movement. CNA #1 provided incontinence care and changed the resident's brief at that time. -Resident #24 went over five hours without being checked for incontinence or being offered toileting assistance. C. Record review The ADL care plan, updated 6/3/24, documented Resident #24 had self-care deficits related to decreased mobility, limited range of motion, a mild right hemiparesis and a cognitive deficit. The resident required supervision and cueing with ADLs. Pertinent interventions included offering and providing assistance with toileting and incontinence care per protocol, conducting routine skin checks per protocol and providing incontinence care promptly after incontinence episodes. According to the CNA task documentation for bladder incontinence, Resident #24 received incontinence care on 4/22/25 at 9:00 a.m. -However, a continuous observation of the resident conducted at that same time revealed the resident was in the common area watching television (see observations above. III. Staff interviews CNA #1 was interviewed on 4/2/25 at 2:02 p.m. CNA #1 said Resident #24 required a pivot transfer. He said he was able to transfer Resident #24 pretty quickly. He said Resident #24 was incontinent and required assistance with incontinence care. He said Resident #24 should be checked every two hours and changed when needed. He confirmed Resident #24 was soiled with urine and a bowel movement when he provided incontinence assistance at 2:02 p.m. after not being checked or changed for over five hours. The director of nursing (DON) was interviewed on 4/3/25 at 4:15 p.m. The DON said facility staff should conduct rounds on residents approximately every two hours. The DON said during these rounds, each resident should be checked to determine if they had an episode of incontinence. She said if a resident was found to be incontinent, staff should offer incontinence care to the resident.

Based on record review and interviews, the facility failed to implement policies and procedures related to influenza and pneumococcal vaccines for two (#26 and #43) of five residents reviewed for immunizations out of 30 sample residents. Specifically, the facility failed to: -Document the influenza vaccine was offered annually for Resident #26 and #43; -Document the pneumonia vaccine was reoffered for Resident #26; and, -Administer the pneumococcal vaccination after consent was provided for Resident #43. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), updated 2025, Recommended Immunization Schedule for Adults Aged [AGE] years or Older, retrieved on 4/10/25 from https://www.cdc.gov/vaccines/hcp/imz-schedules/downloads/adult/adult-combined-schedule.pdf, Pneumococcal vaccination-Routine vaccination-Age [AGE] years or older who have not previously received a dose of PCV13 (pneumococcal conjugate vaccine), PCV15, PC20, OR PCV21 or whose previous vaccination history is unknown: one dose PCV15 or PCV20 or one dose PCV21. If PCV15 is used, administer one dose PPSV23 at least one year after the PCV15 dose (may use a minimum interval of eight weeks for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak). Previously received only PCV7: follow the recommendation above. Previously received only PCV13: one dose PCV20 or one dose PCV21 at least one year after the last PCV13 dose. Previously received only PPSV23: one dose PCV15 or one dose PCV20 or one dose PCV21, at least one year after the last PPSV23 dose. If PCV15 is used, no additional PPSV23 doses are recommended. Previously received both PCV13 and PPSV23 but no PPSV23 was received at age [AGE] years or older; one dose PCV20 or one dose PCV21 at least five years after the last pneumococcal vaccine dose. Previously received both PCV13 and PPSV23, and PPSV23 was received at age [AGE] years or older: Based on shared clinical decision making, one dose of PCV20 or one dose of PCV21 at least five years after the last pneumococcal vaccine dose. II. Facility policy and procedure The Seasonal Influenza, Prevention and Control policy and procedure, revised March 2022, was provided by the nursing home administrator (NHA) on 4/3/25 at 7:18 p.m. It read in pertinent part, All residents and staff are offered the vaccine prior to the onset of the influenza season. All residents and staff are encouraged to receive the vaccine unless there is a medical contraindication. The Vaccination of Resident policy and procedure, revised October 2019, was provided by the NHA on 4/3/25 at 7:18 p.m. It read in pertinent part, All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated. All new residents shall be assessed for current vaccination status upon admission. If the resident receives a vaccine, at least the following information shall be documented in the resident's medical record: site of administration, date of administration, lot number of the vaccine, expiration date and name of person administering the vaccine. III. Resident #26 A. Resident status Resident #26, age 75, was admitted on [DATE] readmitted on [DATE]. According to the April 2025 computerized physician orders (CPO), the diagnoses included pneumonia, type 2 diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD) and vascular dementia. The 1/15/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of five out of 15. She required substantial/maximal assistance with toileting, personal hygiene. She required partial/moderate assistance with bed mobility and was independent with eating. The assessment indicated the resident had been offered and she had declined the influenza vaccine for the years' influenza season. The assessment indicated the resident had been offered and she had declined the pneumonia vaccine. B. Record review A review of the Resident #26's electronic medical record (EMR) on 4/3/25 revealed a consent form for influenza and pneumonia vaccine. The form indicated the resident declined the influenza and pneumonia vaccine on 4/15/22. -A review of the EMR on 4/3/25 failed to reveal documentation that the influenza vaccine or the pneumonia vaccine was reoffered annually. IV. Resident #43 A. Resident status Resident #43, age 74, was admitted on [DATE]. According to the April 2025 CPO, the diagnoses included COPD and stage 4 severe chronic kidney disease (CKD), The 1/8/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 12 out of 15. He was independent with eating, toileting, personal hygiene, bed mobility and transfers. The assessment indicated the resident had been offered and he had declined the influenza vaccine for the years' influenza season. The assessment indicated the resident had been offered and he had declined the pneumonia vaccine. -However, review of Resident #43's consent form revealed the resident indicated he wanted to receive the pneumonia vaccine on 2/17/23 (see record review below). B. Record review A review of Resident #43's EMR on 4/3/25 revealed a consent form for the influenza and the pneumonia vaccine that documented the resident declined the influenza vaccine and wished to receive the pneumonia vaccine on 2/17/23. -A review of the EMR on 4/3/25 failed to reveal documentation of the influenza vaccine being reoffered annually. -A review of the EMR on 4/3/25 failed to reveal documentation that the pneumonia vaccine was administered after the resident signed the consent form for permission to receive the vaccine. V. Staff interviews The director of nursing (DON) was interviewed on 4/3/25 at 2:26 p.m. The DON said that many of the residents declined immunizations because they did not trust the government. She said the consents for immunizations were completed when a resident was admitted to the facility. She said the form was then uploaded into the residents' EMR. She said the information of vaccines received and refused were documented under the immunization tab in the resident's medical record. She said they offered the vaccines every year and the residents' acknowledgment of education of risk versus benefit was documented on the consent.

Based on record review and interview, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of one (#18) of three residents out of 18 sample residents. Specifically, the facility failed to follow procedures to prevent the drug diversion of Resident #18's Ativan (a Schedule IV controlled substance medication for treatment of anxiety). Findings include: I. Professional reference According to [NAME] S Treas, [NAME] L [NAME], [NAME] H [NAME] (2022). Basic Nursing third addition, Controlled substances are drugs considered to have either limited medical use or high potential for abuse or addiction. Under the Controlled Substances Act (CSA) of the comprehensive drug abuse prevention and control act of 1970, it is illegal to possess a controlled substance without a valid prescription. Controlled substances are classified by Schedules. Schedule II controlled substances are drugs that have an acceptable medical use but a high potential for abuse (opium, morphine, oxycodone). Controlled substances must be stored in locked drawers within a second locked area. The facility must keep a record of every dose administered. A count of all controlled substances is performed at specified times, usually at change of shift. To facilitate counting and tracking inventory, drug manufacturers package many narcotics in sectioned containers, with each labeled separately and consequently numbered. II. Facility policy and procedure The Controlled Substance policy, revised November 2023, was provided by the nursing home administrator (NHA) on 11/6/24 at 2:30 p.m. The policy read in pertinent part, The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Drug Abuse Prevention and Control Act of 1976). Only authorized licensed nursing and/or pharmacy personnel have access to Schedule II controlled substances maintained on premises. The director of nursing (DON) services identifies staff members who are authorized to handle controlled substances. Nursing staff count on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. III. Record review Review of the facility's investigation revealed that on 11/1/24, during the 6:00 a.m. shift change, it was discovered that the narcotic count for Resident #18's Ativan was significantly off and a total of 44 Ativan 0.5 milligram (mg) tablets were missing. According to the investigation, the Ativan tablets had been present at the 6:00 p.m change of shift on 10/31/24. The investigation report documented the narcotic count on the [NAME] unit cart was not conducted between the two offgoing and oncoming licensed nurses at 2:00 a.m. on 11/1/24. When the offgoing nurse counted Resident #18's Ativan with the oncoming nurse at 6:00 a.m. on 11/1/24, all four bottles of the resident's Ativan were empty. The investigation report documented the nursing management team was investigating. The three licensed nurses who had the keys to the [NAME] medication cart during the time frame of 6:00 p.m. on 10/31/24 until 6:00 a.m. on 11/1/24 were sent for drug testing. The facility notified the local police department and reported the missing narcotics to the State Agency portal. IV. Staff interviews The NHA and the director of nursing (DON) were interviewed together on 11/6/24 at 12:30 p.m. The NHA said an investigation in regards to the diverted drugs was initiated on 11/1/24. She said the three nurses were all sent for drug testing. The NHA said the nurses' drug test results were all negative. The DON said the nurse did not complete a narcotics count during the change of shift at 2:00 a.m. She said when the 6:00 a.m. nurse came in on 11/1/24, she and the offgoing nurse conducted a narcotics count and that was when Resident #18'sAtivan bottles were discovered to be empty. The DON said the facility notified the police department and the police would be following up with an investigation of the incident.

Based on record review and interviews, the facility failed to maintain accurately documented medical records for two (#4 and #12) of four residents reviewed out of 18 sample residents. Specifically, the facility failed to ensure nursing staff documented skin assessments accurately for Resident #4 and Resident #12. Findings include: I. Facility policy and procedure The Charting and Documentation policy and procedure, undated, was provided by the director of nursing (DON) on 11/7/24 at 11:22 a.m. It read in pertinent part, All services provided to the resident, progress toward the care plan goals and any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. II. Resident #4 A. Resident status Resident #4, age 75, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), adult failure to thrive and generalized muscle weakness. The 10/11/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required minimal assistance with activities of daily living (ADL). B. Resident observation On 11/5/24 at approximately 10:45 a.m. Resident #4 was lying on her bed in her room with her left foot elevated. The resident had an open-to-air wound on the top of her left foot. The wound was approximately three to five inches long and the skin appeared discolored and abnormally dark. C. Record Review The 10/28/24 nurse progress note documented Resident #4 was complaining of swelling and a rash on her right foot and the resident was examined by the nurse practitioner (NP) who gave new orders for treatment. -The progress note documented Resident #4 had a rash on her right foot, however, observation of the resident revealed the resident had a skin condition on her left foot (see observation above). The 10/28/24 provider note written by the NP documented the resident had swelling in her left ankle. -The note failed to document the rash on the resident's foot or the treatment interventions the NP had prescribed. The Head to Toe Skin Assessment flowsheet, dated 10/29/24, documented new swelling and a rash on Resident #4's left foot. A review of Resident #4's November 2024 CPO revealed a physician's order, dated 10/31/24, to monitor Resident #4's ankle swelling daily. -There were no ordered interventions addressing the resident's swelling or rash/wound. 20287 III. Resident #12 A. Resident status Resident #12, age 79, was admitted on [DATE]. According to the November 2024 CPO diagnoses included personal history of transient ischemic attack, hypertension and type II diabetes. The 11/1/24 MDS assessment revealed the resident was cognitively impaired based on the staff assessment for mental status. The resident was unable to recall the current season, the location of his room or staff faces. The MDS assessment indicated the resident had one unstageable pressure injury. B. Record review The admission skin nursing assessment, dated 10/7/24, documented the resident's skin was intact. -However, the skin assessment directed staff to use the diagram on the assessment and document a description of skin concerns The diagram on Resident #12's admission skin assessment indicated there was an open area on the resident's coccyx but there was no description of the wound. -The skin assessment was documented inaccurately as it indicated the resident's skin was intact, however, it also indicated there was an open wound on the resident's coccyx. The 10/7/24 progress notes showed nothing documented about pressure injury. The wound physician progress note dated 10/9/24 documented Resident #12 had a sacral unstageable pressure injury. The measurements were 6 centimeters (cm) in length by 3.5 cm in width by 0.2 cm in depth. IV. Staff interviews The NHA, the DON and the assistant director of nursing (ADON) were interviewed together on 11/7/24 at 12:40 p.m. The NHA, the DON and the ADON all agreed the facility's leadership team were responsible for ensuring staff were documenting correctly and that education had been provided to nursing staff regarding accurate documentation. The NHA said staff required additional training regarding accurate documentation. The ADON said Resident #12 was admitted to the facility with an unstageable pressure injury. The ADON reviewed Resident #12's electronic medical record (EMR) and said the resident's admission skin assessment was inaccurate. The ADON said she would provide education to the nurses about how to assess and accurately document pressure injuries.

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for three (#10 and #16) of four residents reviewed out of 18 sample residents. Specifically, the facility failed to: -Provide Resident #10 and Resident #16 with timely incontinence care; and, -Provide the necessary assistance for Resident #10, who required physical assistance and encouragement with meals. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADLs), Supporting policy, undated, was provided by the director of nursing (DON) on 11/7/24 at 10:41 a.m. It revealed in pertinent part, Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Residents will be provided with care, treatment and services to ensure that their ADLs do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLS are unavoidable. Appropriate care and services will be provided for residents who are unable to carry out ADLSs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, groom and oral care); mobility (transfer and ambulation, including walking); elimination (toileting); dining (meals and snacks); and, communication (speech, language, and any functional communication systems). II. Resident #10 A. Resident status Resident #10, age greater than 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO) diagnoses included anxiety, bipolar disorder (mental illness that causes unusual shifts in a person's mood and behavior) and dysphagia (difficulty swallowing). The 10/11/24 minimum data set (MDS) assessment revealed the resident had short term memory deficits, was cognitively impaired and her daily decisions skills were moderately impaired based on the staff assessment for mental status. She required supervision and touching assistance with meals. The resident was dependent on staff for personal hygiene. The resident was incontinent of bowel and bladder. She was not on a toileting program. B. Observations 1. Meal assistance During a continuous observation of the lunch meal on 11/5/24, beginning at 12:25 p.m. and ending at 1:15 p.m., the following was observed: At 12:25 p.m. an unidentified certified nurse aide (CNA) served the resident her meal in her room .The resident was served a whole baked potato with her meal and the unidentified CNA did not slice it open for her. The resident was not eating her meal. At 12:30 p.m. the resident was not eating and had not received any encouragement or cuing from staff. At 1:03 p.m. the resident self propelled herself and left her room. She had not eaten any of her meal. At 1:15 p.m. the resident remained in the hallway and was not encouraged to return to her meal. -Resident #10 was not provided encouragement or cueing from 12:25 p.m. to 1:15 p.m. During a continuous observation of the dinner meal on 11/5/24, beginning at 4:55 p.m. and ending at 5:21 p.m. the following was observed: At 4:55 p.m. the resident was lying in bed. At 5:04 p.m. the resident was served her meal which consisted of a grilled cheese sandwich with no sides. At 5:07 p.m. Resident #10 was eating half of the grilled cheese sandwich. At 5:21 p.m. the resident was no longer eating the grilled cheese. She stopped eating and did not receive any encouragement. She had fallen asleep. -Resident #10 was not provided encouragement or cueing from 4:55 p.m. until 5:21 p.m. when she fell asleep. 2. Toileting assistance During a continuous observation on 11/6/24, beginning at 9:15 a.m. and ending at 1:15 p.m. the following was observed: At 9:15 a.m. the resident was in the common area self propelling herself in the wheelchair. At 10:00 a.m. the resident was self propelling with the occupational therapist. At 10:30 a.m. the resident continued to sit in her wheelchair and was talking with the occupational therapist. At 11:00 a.m. the resident continued to propel herself throughout the hallway. At 11:30 a.m. Resident #10 continued to propel herself though the hallway. She had not been offered to be checked and changed for urine incontinence or assisted to the bathroom. At 11:54 a.m. Resident#10 was asked if she wanted to go to the dining room. CNA #3 assisted her to the dining room to await her meal. She was not offered any toileting assistance. At 12:15 a.m. the resident received her meal. At 1:15 p.m. Resident #10 was changed. There was redness noted on the resident's bottom and her brief was soiled with urine. -Resident #10 was not offered or provided incontinence care for four hours from 9:15 a.m. until 1:15 p.m. C. Record review The care plan last updated on 6/20/24, identified the resident at nutritional risk related to dementia. She had a history of variable intakes related to dementia. Pertinent interventions included encouraging Resident #10 to eat her meals and if she refused, offer sandwiches or chips.The care plan indicated the resident required cueing at meals. The care plan last updated on 7/30/24 identified the resident required assistance with ADL care in toileting. Pertinent interventions included the resident required assistance for incontinence care. -Review of the care plan did not include how often to offer the resident assistance with incontinence care. D. Staff interviews CNA #1 was interviewed on 11/7/24 at 9:25 a.m. CNA #1 said Resident #10 was able to feed herself, however she did require encouragement and cueing to eat. CNA #1 said the resident would wander off from her meal and become distracted. He said she needed to be assisted back to the dining room or to where she was eating so she could eat. Licensed practical nurse (LPN) #1 was interviewed on 11/7/24 at 10:00 a.m. LPN #1 said Resident #10 was able to feed herself, but she needed and encouragement to eat. She said the resident ate best when she was provided food that the resident could move with, such as a sandwich. She said Resident #10 would leave her plate and it was difficult to get her to come back to the table or her meal tray. Registered nurse (RN) #1 was interviewed on 11/6/24 at 12:29 p.m. RN #1 said he was an agency employee and it was his first day working at this facility. He said he was not aware Resident #10 had not been offered to be toileted or checked and changed recently. He said he reviewed the resident's electronic medical record (EMR) and said the resident's skin was clear, however she was at risk for pressure injuries due to the incontinence. He said the resident should be changed and offered toileting assistance every two hours and prior to meals. III. Resident #16 A. Resident status Resident #16, age 83, was admitted on [DATE]. According to the November 2024 CPO, diagnoses included muscular dystrophy (genetic disease that causes decrease in muscle function), difficulty in walking, weakness and adult failure to thrive. The 9/17/24 MDS assessment revealed Resident #16 was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was dependent on staff for toileting hygiene. The assessment indicated the resident was not on a toileting program and was frequently incontinent of bowel and bladder. B. Resident interview Resident #16 was interviewed on 11/5/24 at 5:41 p.m. Resident #16 said he was often not provided assistance with changing after an incontinence episode. He said on the night shift on 11/2/24 he was not changed for over three hours he said he slept in pee. He said it was terrible. He said he had complained to the staff prior, however he had not seen any improvement. C. Record review The care plan last updated on 10/7/24 identified the resident had self care deficit related to muscular dystrophy. -Review of the resident's comprehensive care plan did not reveal any approaches related to the resident's incontinence. The 11/2/24 call light audit revealed Resident #16's call light was activated at 3:45 a.m., and it was not answered for 37 minutes. D. Staff interview The director of nursing (DON) was interviewed on 11/7/24 at 12:03 p.m. The DON said Resident #16 used his call light frequently. She said the resident refused to use the urinal. The DON said call lights should be answered within 15 minutes.

Based on observations, record review and interviews, the facility failed to take steps to protect one (#1) of five residents reviewed for abuse out of 18 sample residents. Specifically, the facility failed to ensure Resident #1 was kept free from physical abuse by Resident #2. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy and procedure, revised September 2022, was provided by the nursing home administrator (NHA) on 11/6/24 at 1:49 p.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish which can include staff to resident abuse and resident to resident altercations. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to, responding immediately to protect the alleged victim and integrity of the investigation, examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed, increased supervision of the alleged victim and residents, room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator, protection from retaliation, providing emotional support and counseling to the resident during and after the investigation, as needed and revision of the resident's care plan if the resident's medical, nursing, physical, mental or psychosocial needs or preferences change as a result of an incident of abuse. II. Incident of physical abuse between Resident #1 and Resident #2 on 8/9/24 The 8/9/24 facility abuse investigation documented the allegation occurred on 8/9/24 at 7:30 p.m. The investigation documented Resident #2 saw Resident #1 touching the videocassette recorder (VCR) and told him to stop. Resident #2 was observed hitting Resident #1 in the mouth/nose. The residents were immediately separated. Certified nurse aide (CNA) #4 notified the nurse of the events. Resident #1's lower lip was red, swollen and slightly bleeding. The investigation documented CNA #4 witnessed the resident-to-resident altercation and Resident #2 was placed on monitoring. It documented Resident #1 was an at-risk adult. The police, residents' families, the ombudsman and the physician were notified of the resident-to resident-altercation. Resident #1 was assessed by the assistant director of nursing (ADON) on 8/9/24 at 7:30 p.m. Resident #1 sustained two small cuts to his lower lip with some swelling. The ADON cleaned Resident #1's lip and applied ice. Resident #1 was at his baseline. The investigation documented the ADON interviewed Resident #1 following the incident. Resident #1 was unable to verbalize what occurred, showed no signs of fear of agitation, was smiling and was eating a peanut butter sandwich. There were no non-verbal responses or behavioral changes observed. The investigation documented Resident #1 had been involved in three previous resident-to-resident altercations, allegations or events. The investigation documented Resident #2 was interviewed by the ADON on 8/9/24 at 7:40 p.m. Resident #2 said Resident #1 was playing with the VCR and had his fingers in it. Resident #2 said he told Resident #1 to stop but he did not listen. Resident #2 said he grabbed Resident #1's arm to stop him. Resident #2 said Resident #1 swung at him but did not hit him. Resident #2 said he hit Resident #1. There were changes in the resident's behavior. The investigation documented Resident #2 had not been involved in any previous allegations, altercations or events. The investigation included a statement, dated 8/12/24, from CNA #4 who witnessed the altercation. She said she heard a verbal argument in the television room. She said when she entered the area, Resident #2 and Resident #1 were sitting next to one another near the television in their wheelchairs. She said she saw Resident #2 hit Resident #1 with a closed fist in the nose and mouth. She said Resident #2 also had ahold of Resident #1's left forearm with a tight grip. She said the nurse removed Resident #1 and assessed Resident #1 because his lower lip was swollen and bleeding a little bit. The investigation included a statement, dated 8/9/24, from the ADON. The ADON said at approximately 7:50 p.m., she was notified that Resident #2 punched Resident #1 in the mouth. The ADON said when she approached Resident #1, he was eating a sandwich and looked up at her and smiled. The ADON said Resident #1's lower lip was swollen on the right side and there were two small, fresh appearing cuts on his lip. She said the areas surrounding the cuts were mildly pink but not actively bleeding. Resident #1 said his mouth did not hurt. Resident #1 was not able to report what happened or if he was afraid of anything or anyone. The ADON said she also interviewed Resident #2 (see Resident #2 interview above). The investigation documented the plan of action included separating the residents immediately. Resident #1 was placed on frequent checks. The residents resided on opposite ends of the hall and the incident happened in the television common room. Resident #2, who was alert and oriented, was educated not to put himself in that situation and to let staff handle situations with other residents. Resident #2 agreed. The investigation concluded the abuse was substantiated. III. Resident #1 - victim A. Resident status Resident #1, age 83, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included dementia with other behavioral disturbances, major depressive disorder, cognitive communication deficit, need for assistance with personal care and muscle weakness. The 9/12/24 minimum data set (MDS) assessment revealed the resident had short term and long term memory problems and was severely impaired with daily decisions per staff assessment. He required set-up assistance for eating. He required substantial assistance with eating and was dependent on staff for toileting, showering and personal hygiene. The MDS assessment revealed the resident displayed physical behaviors directed towards others one to three days in the review period. B. Record review The care plan, revised on 4/19/24, documented Resident #1 had impaired cognitive function and or impaired thought processes related to dementia. The care plan indicated the resident had displayed verbal or physical aggression towards staff and was an elopement risk. Pertinent interventions included keeping the resident's routine consistent, providing consistent caregivers in order to decrease confusion, cueing, reorienting and supervising the resident as needed, monitoring for target behavior symptoms (pacing, wandering, disrobing, inappropriate responses, violence/aggression towards staff and other residents) and monitoring for effectiveness of medication administration. The 8/10/24 nursing progress note documented by registered nurse (RN) #2 revealed that Resident #1 was in an altercation with Resident #2 because he was doing something that Resident #2 did not like it. Resident #1 was swinging his fists but did not make contact with Resident #2. Resident #2 then struck Resident #1 on the mouth. Upon assessment, Resident #1 had a bloody, swollen lip with a small scab forming. The altercation was unwitnessed by RN #2. The ADON was notified for further instructions. -Review of Resident #1's electronic medical record (EMR) did not reveal further documentation, monitoring or assessments, besides the 8/10/24 nursing progress note, following the resident-to resident-altercation on 8/9/24. IV. Resident #2 - assailant A. Resident status Resident #2, age 73, was admitted on [DATE]. According to the July 2024 CPO, diagnoses included post traumatic stress disorder (PTSD), depressive disorder, morbid obesity and diabetes. The 8/29/24 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He required setup assistance with eating and oral hygiene. He required substantial assistance with toileting and showering. He required moderate assistance with personal hygiene. The MDS assessment indicated the resident did not have any behaviors in the review period. B. Record review The care plan, revised on 7/8/24, documented Resident #2 had displayed behaviors that included verbal outbursts, throwing items at staff, urinating on the floor and refusing care and showers. He described himself as stubborn and required time alone to calm down when agitated, as he did not respond well to redirection when he was upset. Resident #2 responded well to direction from his sons when he was at his baseline mood state. Pertinent interventions included respecting the resident's preferences for privacy, specifically avoiding others, allowing the resident to remain as independent as possible as related to self care, providing the resident the right to choose mental health services, providing the resident with positive interaction, discussing the resident's behavior when he was de-escalated and explaining why it was inappropriate, intervening to protect the rights and safety of others, approaching the resident in a calm manner, monitoring behavior patterns (location, time of day, persons involved and situations) and monitoring effectiveness of medications. A review of Resident #2's EMR revealed the resident was on safety checks every 30 minutes for 72 hours following the resident-to-resident altercation on 8/9/24. V. Staff interviews Licensed practical nurse (LPN) #1 was interviewed on 11/7/24 at 10:23 a.m. LPN #1 said she had not witnessed any resident-to-resident altercations. LPN #1 said Resident #2 usually spent the day alone in his room and only came to the common area to watch television on occasion or if his spouse visited. LPN #1 said Resident #2 had behaviors, she had not been provided specific training to meet the needs of Resident #2's behavior. CNA #5 was interviewed on 11/7/24 at 10:44 a.m. CNA #5 said he had not received training regarding resident specific behaviors. The ADON was interviewed on 11/7/24 at 12:16 p.m. The ADON said the staff received verbal updates at shift change regarding residents' behaviors and the staff had access to the Kardex (a staff directive tool) which was updated with resident specific information.

Based on record review and interviews, the facility failed to notify the physician timely for one (#15) of three residents reviewed out of 18 sample residents. Specifically, the facility failed to ensure Resident #15's physician was notified when the resident consistently refused her anticoagulant medication (medication used to decrease the risk of stroke and blood clots). Findings include: I. Resident #15 A. Resident status Resident #15, age 65, was admitted on [DATE]. According to the November 2024 computerized physician orders (CPO), diagnoses included infection and inflammatory reaction due to internal right knee prosthesis, end-stage renal disease, atrial fibrillation (irregular heart rhythm) and peripheral vascular disease. The 10/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required maximum assistance with toileting, showering and transfers. No documentation in MDS assessment, dated 10/10/24, was found stating the resident was receiving anticoagulant medication. B. Record review The 11/4/24 nurse practitioner (NP) follow-up note documented Resident #15 was on Eliquis as a treatment for her atrial fibrillation. Review of Resident #15's November 2024 CPO revealed the resident had a physician's order for Eliquis 2.5 milligrams (mg) by mouth two times a day for atrial fibrillation, ordered 4/16/24. Resident #15's October 2024 medication administration record (MAR) revealed the resident refused her Eliquis medication on 40 out of 62 opportunities for administration. Review of the resident's November 2024 MAR revealedResident #15 refused her Eliquis medication on six out of 11 opportunities for administration. The nursing note dated 9/3/24 at 9:36 p.m. documented Resident #15 refused her Eliquis due to a concern that her dialysis fistula would bleed the following day once her bandage was removed. The registered nurse (RN) documented the resident was educated on the use of Eliquis and her need to take it, yet the resident still refused. -The note did not reveal that the resident's physician was notified regarding the resident's refusal of the medication. -Review of Resident #15's electronic medical record (EMR) revealed there were no progress notes documented in October 2024 to indicate the resident's physician had been notified of the resident's frequent refusals of the Eliquis medication (see MAR above). The nursing note dated 11/7/24 at 12:04 p.m. documented Resident #15 refused her Eliquis that morning. The RN documented that she explained the consequences of refusing the medication and the resident stated I don't care. The RN documented the provider was notified and that she was advised to continue offering the medication to the resident. -However, there were no further progress notes documented to indicate the resident's physician had been notified the other five times she had refused the medication in November 2024 (see MAR above). C. Staff interviews RN #1 was interviewed on 11/7/24 at 11:10 a.m. RN #1 said Resident #15 frequently refused to take her Eliquis on days she received dialysis treatment due to long bleeding times. RN #1 said she often educated the resident on the benefits versus the risks of taking/not taking her medication. RN #1 said she was supposed to offer the resident her medication two to three times, and if the medication was continually refused, refusals were to be documented in the MAR and the progress notes and the provider should be notified. The assistant director of nursing (ADON) was interviewed on 11/7/24 at 12:40 p.m. The ADON said the staff were supposed to offer medications to residents three times. She said if the resident continued to refuse, then staff were supposed to document the refusal in the MAR and progress notes and notify the provider. The facility's NP was interviewed on 11/7/24 at 2:42 p.m. The NP said that nurses would occasionally tell her Resident #15 was refusing her Eliquis. However, she said the nurses mentioned it in passing and she did not know the resident was refusing the medication so frequently. She said she would discuss discontinuing the medication with the resident and the resident's representative.

Based on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to ensure control measures for monitoring and preventing Legionella and waterborne pathogens growth were included in the facility's water management plan. Findings include: I. Professional reference The Center for Disease Control and Prevention (CDC) recommendations for Legionella, last reviewed on 3/25/21, was retrieved on 10/22/23 at https://www.cdc.gov/legionella/wmp/healthcare-facilities/healthcare-wmp-faq.html under Heathcare Water Mangement read in pertinent part: Healthcare facilities, such as hospitals and nursing homes, usually serve the populations at highest risk for Legionnaires' disease. These include older people and those who have certain risk factors, such as being a current or former smoker, having a chronic disease, or having a weakened immune system. Also, healthcare facilities can have large complex water systems that promote Legionella (the bacterium that causes legionnaires' disease) growth if not properly maintained. For these reasons, the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) consider it essential that hospitals and nursing homes have a water management program that is effective in limiting legionella and other opportunistic pathogens of premise plumbing (waterborne pathogens, for short) from growing and spreading in their facility. Legionella and other waterborne pathogens occur naturally in the environment, in bodies of water like lakes, [NAME], and streams. Although municipalities treat their water with disinfectants like chlorine that can kill these pathogens, a number of factors may allow these pathogens to enter a building's water distribution system, such as construction (including renovations and installation of new equipment). Vibrations and changes in water pressure can dislodge biofilm and release legionella or other waterborne pathogens. Biofilm is a slimy layer in pipes in which pathogens can live; it can give pathogens a safe harbor from disinfectants. Water management programs identify hazardous conditions and take steps to minimize the growth and spread of legionella and other waterborne pathogens in building water systems. Developing and maintaining a water management program is a multi-step process that requires continuous review. In general, the principles of effective water management include: -Maintaining water temperatures outside the ideal range for legionella growth (77-113 Fahrenheit). -Preventing water stagnation. -Ensuring adequate disinfection. -Maintaining premise plumbing, equipment, and fixtures to prevent sediment, scale, corrosion, and biofilm, all of which provide a habitat and nutrients for legionella. Members of a building water management program team work together to: -Identify ways to minimize growth and spread of legionella and other waterborne pathogens. -Conduct routine checks of control measures to monitor areas at risk. -Take corrective action if a problem is found. Once established, water management programs require regular monitoring of key areas for potentially hazardous conditions. Programs should include predetermined responses to correct hazardous conditions if the team detects them. II. Facility policy and procedure The Legionella Water Management Program policy and procedure, undated, was provided by the nursing home administrator (NHA) on 10/17/23 at 3:00 p.m. It revealed in pertinent part, Legionalla an grow in many parts of of the building water systems that are continually wet, and certain devices can then spread contaminated water droplets. Examples include but are not restricted to: water heaters, water filters, electronic and manual faucets, showerheads and hoses, ice machines, pipes, valves and fittings, cooling towers, medical devices (such as CPAP machines) and evaporative coolers. If a control limit is not being met, you need to take corrective actions to get the conditions back to within an acceptable range. If three is any time there is a suspected case of Legionnaires disease associated with your building you should decontaminate the building water system if necessary and review the water management program and review it if necessary. Control measures and limits will be established for each control point. You will need to monitor to ensure your control measures are performing as designed. A list of interventions known to eliminate legionella: prevention is the best intervention, ten to one bleach solution, heating water to above 160 degrees and water movement (stagnant water allows Legionalla to grow). -The interventions included in the Legionella Water Management Program did not include additional details on how or where to administer and monitor a ten to one bleach solution, how to monitor heating water to above 160 degrees fahrenheit at the source and throughout the flow of water through the facility or how to determine the effectiveness of these interventions. The Legionella Water Management Program did not include specific facility locations monitored such as water heaters, water filters, electronic and manual faucets, showerheads and hoses, ice machines, pipes, valves and fittings, cooling towers, medical devices (such as CPAP machines) and evaporative coolers. III. Record review The weekly water systems testing and monitoring spreadsheet was provided by the NHA on 10/19/23 at 10:20 a.m. The spreadsheet documented monthly and weekly monitoring from 10/1/22 to 10/31/23. The monthly monitoring included an inspection of the eyewash stations. The weekly monitoring included testing and monitoring of the water management plan for Legionella with a corresponding completion date. -The water systems testing and monitoring spreadsheet did not include specific locations monitored in the facility such as water heaters, water filters, electronic and manual faucets, showerheads and hoses, ice machines, pipes, valves and fittings, cooling towers, medical devices (such as CPAP machines) and evaporative coolers. The spreadsheet did not indicate how many eyewash stations were inspected. IV. Staff interviews The NHA, the maintenance supervisor and regional maintenance supervisor (RMS) were interviewed on 10/19/23 at 10:00 a.m. The RMS said there was a document in the electronic building and asset management system that contained specifics on which facility locations to monitor. The RMS said the water management plan was for the facilities in their corporation, but each facility might have different items or locations specifically to monitor. The RMS said he could enter the specific facility locations to monitor into the electronic building and asset management system and add to the water management binder the steps to take if the facility had to turn up the temperature on boilers. The MS said the facility halls had separate boilers and one boiler could be adjusted if a single hall was found to have an issue. The MS said water for certain sections can be closed off to control which hallway was monitored. The NHA said if if there was possible contamination the facility water temperature could be increased. The NHA said if the water temperature was increased, the facility would implement the same plan used when the facility previously repaired facility pipes. The residents did not use the water and staff were notified of the changes. The NHA said the unused resident room on the other side of the building were part of the facility monitoring and the goal was to someday use those rooms again. The RMS said the MS checked sections of pipes that were rarely or not used, swamp coolers and the shower room on the closed hall for any signs of Legionella. The RMS if there were signs of Legionella contamination when the facility tested then Ecolab conducted tests at the facility. V. Facility follow-up The RMS added specific facility locations in addtion to the eyewash stations that were monitored to the electronic building and asset management system on 10/19/23 at 11:00 a.m.

Based on observations, record review and interviews, the facility failed to ensure one (#14) of eight out of 32 sample residents received adequate supervision to prevent accidents. Specifically, the facility failed to ensure Resident #14 received the supervision he required to prevent falls. Findings include: I. Resident #14 Resident #14, age under 65, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included Huntington's Disease, Parkinson's disease, vascular dementia without behavioral disturbance, chorea (a neurological disorder characterized by spasmodic involuntary movements of the limbs or facial muscles), muscle weakness, depression, repeated falls, lack of coordination, functional urinary incontinence and unsteadiness on feet. The 9/29/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. He required extensive assistance of one person with bed mobility, transfers, eating and personal hygiene and total dependence of one person with toileting and dressing. It indicated the resident had two or more falls since the prior assessment. A. Resident interview and observations Resident #14 was interviewed on 10/16/23 at 1:45 p.m. He said he had experienced a lot of falls. He said at first he had a difficult time accepting he could not do certain things, but that lately his falls were because the facility staff took a long time to help him. He said he needed help with almost everything. On 10/16/23 at 3:22 p.m. Resident #14 could be heard calling out for help from the hallway before rounding the corner to the nursing station. Two staff members were observed sitting in the nursing station, looking down at their cell phones. Resident #14's room was directly across from the nursing station and could be heard calling out for help. The call light was activated. Resident #14 was observed on the floor, with his left leg tangled in the wheelchair with a urine puddle on the ground. Upon notifying an unidentified staff member that Resident #14 was on the ground, tangled in his wheelchair, the staff member said, um ok. She finished looking at something on her cell phone, placed her cell phone down and entered the resident's room. She said to the resident she needed to get gloves and other items and would be back to help him off the ground. She returned with a nurse to assist. On 10/17/23 at 1:31 p.m. Resident #14's call light had been activated, along with two other call lights. Resident #14 was observed calling out for help. Staff members were observed sitting at the nursing station, not getting up to attend to any of the call lights. Activity assistant (AA) #1 was observed entering each of the rooms of the activated call lights. AA #1 informed licensed practical nurse (LPN) #3 that three call lights had been activated, staff were sitting in the nursing station and all three residents required incontinence care. B. Record review The cognitive care plan, initiated on 7/24/23 and revised on 10/13/23, documented the resident had impaired cognitive function related to a diagnosis of dementia. The interventions included administering medications as ordered, asking yes or no questions to determine the resident's needs, communicating with the resident regarding his capabilities and needs and keeping the resident's routine consistent to decrease confusion. The communication care plan, initiated on 8/15/22 and revised on 10/13/23, documented that the resident had potential for complications due to impaired communication exhibited by unclear speech and difficult to understand. The resident had effects of chorea on vocalization. The interventions included allowing the resident time to respond, express himself and understand others; asking the resident for clarification as needed; providing the resident with appropriate adaptive equipment and observing any changes to his communication. The activities of daily living (ADL) care plan, initiated on 8/15/22 and revised on 2/21/23, documented that the resident had severe chorea that impacted his ability for self-care. He was able to feed himself with finger foods, but was unable to use utensils safety or effectively. It indicated the resident had impaired vision, was forgetful and his speech was unclear at times. The interventions included offering and assisting the resident with transfers and bed mobility; and offering and providing assistance with grooming, oral/dental care, personal hygiene, meals and incontinence care. The fall risk care plan, initiated on 8/15/22 and revised on 4/21/23, documented that the resident was at risk for injuries from falls due to decreased coordination and a history of falls. The resident had uncontrolled tremors. It indicated that the resident chose to transfer without assistance. The interventions included providing safety devices, assistive equipment, dycem under the cushion to prevent slipping, therapy for transfer training; providing verbal reminders not to transfer without assistance; encouraging the resident to call for help when needed; keeping the call light within reach and responding promptly; providing a low bed for safety; providing anti-rollbacks for the wheelchair; and removing the foot pedals from the wheelchair. 1. Fall incident 2/13/23 According to the 2/13/23 interdisciplinary (IDT) team fall committee progress note, the resident sustained an unwitnessed fall while self-transferring from the recliner to his wheelchair to go to dinner. The resident lost his balance and fell to the ground. The resident sustained a laceration to the top of the right side of his head. There was minimal bleeding and no swelling noted. The interventions included offering the resident a helmet for safety and continuing to encourage the resident to ask for assistance with transfers. 2. Fall incident 3/3/23 The 3/3/34 nursing progress note documented the resident was found on the floor twice, within a few minutes of each other. The resident was unable to verbalize what caused the fall. The resident did not sustain any injuries. -It did not include any new interventions. 3. Fall incident 4/3/23 The 4/3/23 nursing progress note documented that at 1:00 p.m., the resident was seen by staff and another resident transferring himself from the wheelchair to the recliner. He made it to the arm of the chair and slid to the floor. He said he did not hit his head. The resident did not sustain any injuries. The interventions included reminding the resident to call for help when he is ready to transfer back to his wheelchair. The 4/4/23 post fall evaluation documented to continually encourage the resident to ask for assistance and that the current interventions were in place to promote safety when the resident falls rather than reducing falls. It indicated that the resident's falls were unavoidable. The 4/5/23 nurse practitioner progress note documented the falls with the resident were unfortunately unavoidable due to his diagnosis of Huntington's disease and severe chorea movements. -However, according to the observations, the resident not only vocalized needing assistance but had also activated his call light with staff close by at the nursing station. The staff did not respond to the call light or the yelling out for help until prompted. The resident was on the floor with evidence of an incontinence episode. 4. Fall incident 4/20/23 The 4/20/23 nursing progress notes documented the nurse was notified that the resident landed on his bottom during a self-transfer from the wheelchair to the recliner in the front lobby, lost his footing and fell . The resident did not sustain an injury. -It did not include any additional interventions. The 4/21/23 IDT fall committee progress note documented the resident was educated again on asking for help when transferring. 5. Fall incident 5/7/23 The 5/7/23 nursing progress note documented that the resident was found on the floor. He said he was transferring himself from the wheelchair to the bed and slid off his chair. The resident did not sustain any injuries. The interventions included frequent visual monitoring for the resident's needs and safety and ensuring the call light is within reach at all times. -However based on the observations, the resident's needs were not addressed timely after the resident had activated his call light and called out for help. 6. Fall incident 7/11/23 The 7/11/23 nursing progress note documented that the resident was on the phone, talking excitedly, and popped out of his wheelchair and landed on the floor. The resident did not sustain an injury. -No new interventions were in place. 7. Fall incident 8/13/23 The 8/13/23 nursing progress note documented at 1:00 p.m. the resident was found sitting on the floor in front of his wheelchair. The resident said he tried to transfer himself and landed on the ground. The resident did not sustain an injury. The resident was strongly encouraged to always call when he would like to be transferred. 8. Fall incident 9/6/23 The 9/6/23 nursing progress note documented the resident was found on the floor, on his buttocks with his legs extended in front of him, with the wheelchair facing the opposite direction. The certified nurse aide (CNA) said she was assisting the resident at the sink prior to bed. She attempted to help the resident sit back in the wheelchair, but because of the foot pedals, the wheelchair moved backwards. The resident was lowered to the floor by the CNA. 9. Fall incident 9/24/23 The 9/24/23 situation, background, assessment and recommendations (SBAR) documented that the resident sustained a fall. -It did not provide any additional details. The 9/25/23 IDT fall committee progress note documented the resident was found on the floor next to his bed, reaching for his IPad. The resident did not sustain an injury. The intervention included therapy evaluating the resident's room. 10. Fall incident 10/15/23 The 10/15/23 nursing progress note documented that the resident fell from the low bed to the floor and then crawled out to the doorway. The resident was assisted with incontinence care upon his request. The resident did not sustain an injury. 11. Fall incident 10/16/23 The 10/16/23 nursing progress note documented that the CNA told the nurse that the resident was found on the floor, in his room, in front of his wheelchair. The resident was soiled with urine. The resident said he slipped from the cushion on his wheelchair because of the urine. The resident did not sustain an injury. II. Staff interviews CNA #2 was interviewed on 10/19/23 at 11:30 a.m. She said Resident #14 required assistance with all ADLs. She said the resident was incontinent and required assistance with incontinence care. She said the resident was able to activate his call light when it was within reach, but that sometimes he would call out for assistance. She said the resident had a difficult time communicating and was difficult to understand at times. She said Resident #14 had sustained a lot of falls. She said the resident usually fell because he wanted to get up out of bed or needed incontinence care and he did not want to wait any longer. She said it depended on the day and what was happening if she was able to assist him timely. She said the resident often did not like to wait for an extended period of time and would attempt to transfer himself. She said she did not think the involuntary movements from his disease were the cause of most of his falls. The director of nursing (DON) was interviewed on 10/19/23 at 1:57 p.m. She said Resident #14 required total assistance with ADLs. She said he had sustained a lot of falls. She said the resident had difficulty accepting the change in his level of care and would self-transfer, which caused the falls. She said the resident was able to activate his call light and would sometimes yell out for help. She said the resident was in the room directly across from the nursing station so staff could assist the resident quickly. The DON said she was not aware of the two observations made on 10/16/23 and 10/17/23, during the survey process. She said the staff should not be sitting in the nursing station on their cell phones. She said if they had down time, then they should be rounding and checking on the residents. She said the staff were aware that Resident #14 would yell for assistance and that should have alerted them to check on him.

Based on interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#51) of two reviewed for change of condition out of 32 sample residents. Specifically, the facility failed to ensure: -A cardiology appointment was scheduled for Resident #51 with a diagnosis of heart failure; and, -The physician was notified when Resident #51 had chest pain. Findings include: I. Resident #51 status Resident #51, age 72, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included chronic obstructive pulmonary disease (COPD), chronic kidney disease stage four and obstructive and reflux uropathy (obstructive urinary flow). The 10/11/23 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview of mental status (BIMS) score of 13 out of 15. He was independent with all activities of daily living. A. Record review Resident #51 was admitted to the hospital from the facility on 6/17/23 for shortness of breath and was discharged from the hospital back to the facility on [DATE]. The hospital discharge instructions recommended a follow-up with cardiology due to a new diagnosis of heart failure with an ejection fraction of less than 40%. The discharge papers instructed the primary care physician (PCP) be notified of signs and symptoms of chest pain or shortness of breath. A nurse's note entered on 7/9/23 at 11:34 p.m. revealed the resident had dry heaves, sweating, nausea, sharp chest pain described as greater than 10 out 10 and shortness of breath. His vital signs were respirations of 26 (normal rate is 12 to 18), heart rate of 68, oxygen saturation of 93% out of 100% and blood pressure of 202/94 (normal range is less than 120 and less than 80). The note documented the nurse remained with the resident for 20 to 30 minutes and the chest pain had decreased to seven to eight out of 10 and the resident wanted to go bed. -There was not any documentation to show that the nurse notified the physician of the residents chest pain and shortness of breath. II. Staff interviews The director of nursing (DON) was interviewed on 10/18/23 at 5:25 p.m. She said she looked through all of the documentation on Resident #51's chart and could not locate where the physician was notified of the residents complaint of chest pain and shortness of breath. She said she would have called the physician if she were the nurse responsible for that resident that night. The physician was interviewed on 10/19/23 at 9:27 a.m. He said he does not recall being informed of any chest pain events in July 2023 for Resident #51. He said he would not want a nurse to make the decision without contacting a physician if a resident complained of chest pain. He said he would expect a phone call. The DON was interviewed again on 10/19/23 at 1:53 p.m. She said Resident #51 had not been seen by a cardiologist for an ischemic workup as recommended by the discharge instructions from his hospital stay that ended on 7/5/23 and the physicians note dated 7/6/23. She said the resident was not having a heart attack and he was seen by cardiology on 7/24/23 to be cleared for fistula surgery. She said he did not come back from hospital with a heart failure diagnosis and that he had atrial fibrillation from pneumonia and end-stage kidney failure. She said she did not believe the cardiac recommendations were for cardiac problems. -However, the hospital discharge instructions indicated the resident was to be seen by cardiology due to a new diagnosis of heart failure (see above). The assistant director of nursing (ADON) was interviewed on 10/19/23 at 5:27 p.m. She said she remembered the night that Resident #51 was outside dry heaving and complaining of chest pain. She said she did not call the doctor and she did not have a good reason for not doing so. She said she it was not in her scope of practice as a licensed practical nurse (LPN) to determine if the resident was having a heart attack and she would have expected her staff to call the physician for direction.

Based on observations, interviews, and record review, the facility failed to ensure two (#1 and #11) of four residents reviewed out of 32 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to: -Ensure Resident #1 and #11 received showers; and, -Ensure Resident #1 and Resident #11's care plan addressed shower refusals and preferences. Findings include: I. Facility policy and procedure The Bath, Shower/Tub policy, revised Feburary 2018, was provided by the director of nursing (DON) on 10/18/23 at 5:13 p.m. It revealed in pertinent part, The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. II Resident #1 A. Resident status Resident #1, under the age of 65, was admitted on [DATE]. According to the September 2023 computerized physician orders (CPO) the diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side (decreased movement of the right side following a stroke), cerebral palsy (weakness of the muscles), need of assistance with personal care and history of traumatic brain injury. The 8/4/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) with a score of nine out of 15. He required supervision of one person for bed mobility, toileting. He required supervision, set-up assistance for transfers, locomotion on and off the unit, eating. He required limited assistance of one person for dressing, personal hygiene. According to the MDS the resident did not have a shower in the review period. B. Observations On 10/16/23 at 9:59 a.m. Resident #1 was in his room. His hair appeared wet and greasy. Resident #1 had a body odor. On 10/17/23 at 8:54 a.m. Resident #1 was in his room. His hair appeared wet and greasy. Resident #1 had a body odor. On 10/18/23 at 10:37 a.m. Resident #1 was in his room. His hair appeared wet and greasy. Resident #1 had a body odor. C. Record review The director of nursing (DON) provided Resident #11's bathing log from 7/18/23 through 10/18/23 on 10/18/23. The July 2023 (7/18/23 to 7/31/23) shower documentation revealed Resident #1 refused a shower on 7/29/23. -It indicated Resident #1 did not receive a shower on six of six opportunities. The August 2023 shower documentation revealed Resident #1 received a shower on 8/9, 8/11 and 8/15/23. Resident #1 refused a shower on 8/19/23. -It indicated Resident #1 received a shower on three of 13 occasions. The September 2023 shower documentation revealed Resident #1 received a shower on 9/5 and 9/15/23. Resident #1 refused a shower on 9/4, 9/11, 9/13, 9/18, 9/20, 9/22, 9/25 and 9/27/23. -It indicated Resident #1 received a shower on two of 13 opportunities. The October 2023 (10/1/23 to 10/18/23) shower documentation revealed Resident #1 received a shower on 10/1, 10/2, 10/4, 10/6, 10/7, 10/8, 10/9, 10/12, 10/13, 10/15 and 10/16/23. -However, certified nurse aide (CNA) #8 was interviewed and said she did not provide Resident #1 a shower on 10/16/23 (see interviews below). -Review of the resident's medical record revealed there were no progress notes to indicate why the resident refused showers on multiple dates. A review of Resident #1's care plan did not indicate techniques to help encourage Resident #1 to bathe. III. Resident #11 A. Resident status Resident #11, under the age of 65, was admitted on [DATE] and readmitted on [DATE]. According to the October 2023 CPO the diagnoses included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side (decreased movement of the right side of the body following a stroke), epilepsy (seizure disorder), gastro-esophageal reflux disease (GERD) and mood disorder. The 9/29/23 MDS assessment revealed the resident had moderate cognitive impairments with BIMS of 12 out of 15. She required supervision with one person assistance for bed mobility. She required limited assistance of one person for transfers, dressing and personal hygiene. She required physical help limited to transfer only for bathing. B. Observations On 10/16/23 at 2:25 p.m. Resident #11 was in the activity room. Resident #11 was wearing jeans and a red shirt. Resident #11 had a hat on. Resident #11's hair appeared greasy and wet. Resident #11 had body odor. On 10/16/23 at 1:20 p.m. Resident #11 was in the hallway wearing the same jeans and red shirt as 10/17/23. Resident #11 was wearing a hat and her hair was greasy and appeared wet. Resident #11 had body odor. C. Record review The activities of daily living (ADL) care plan, initiated on 10/18/21 and revised on 6/3/22, revealed Resident #11 required assistance with some ADLs. Resident #11 became frustrated easily with communicating her need for assistance with ADLs at times. The interventions included in pertinent part: allowing and encouraging Resident #11 to make her decisions of care, allowing sufficient time for her to complete tasks independently and bathing per resident's current preference. The activities care plan, initiated on 10/18/21 and revised on 8/14/23, revealed Resident #11 preferred a shower with female assistance. Resident #11 needed encouragement and reassurance for showering. The director of nursing (DON) provided Resident #11's bathing log from 7/18/23 through 10/18/23 on 10/18/23. The July 2023 (7/18/23 to 7/31/23) shower documentation revealed Resident #11 refused a shower on 7/28/23. -It indicated Resident #11 was not provided a shower out of four opportunities. The August 2023 shower documentation revealed Resident #11 received a shower on 8/11, 8/16, 8/18 and 8/29/23. -It indicated Resident #11 was provided a shower on three of nine opportunities. The September 2023 shower documentation revealed Resident #11 received a shower on 9/4, 9/5, 9/12, 9/15, 9/19, 9/22 and 9/26/23. -It indicated Resident #11 was provided a shower on six of eight opportunities. The October 2023 (10/1/23 to 10/18/23) shower documentation revealed Resident #11 received a shower on 10/1, 10/2, 10/4, 10/5, 10/6, 10/8, 10/11, 10/13, 10/14 and 10/15/23. -It indicated Resident #11 was provided a shower on two of five opportunities. IV. Staff interviews CNA #7 was interviewed on 10/18/23 at 4:01 p.m. CNA #7 said there were bath sheets in the nurses station that indicated each resident's preference for baths. CNA #7 said Resident #11 preferred to shower on Tuesday and Fridays on the evening shift. CNA #7 said Resident #1 preferred to shower Monday, Wednesday and Friday on the evening shift. CNA #8 was interviewed on 10/18/23 at 6:48 p.m. CNA #8 said she typically worked the evening shift. CNA #8 said Resident #11 occasionally refused showers. CNA #8 said Resident #11 responded well to a rewards system. CNA #8 said if Resident #11 refused a shower, she would reapproach the resident later and offer her a cigarette. CNA #8 said the cigarette helped encourage Resident #11 to shower. CNA #8 said Resident #1 occasionally refused showers. CNA #8 said she would attempt to help Resident #1 shower three times prior to documenting that he refused the shower. CNA #8 said she would also notify the nurse. CNA #8 said Resident #8 did not receive a shower on 10/16/23 or 10/17/23. Registered nurse (RN) #4 was interviewed on 10/19/23 at 10:55 a.m. RN #4 said CNAs were responsible for assisting residents with showers. RN #4 said a bath aide was scheduled on the day shift. RN #4 said the scheduled evening CNAs were responsible for assisting with showers on their assigned unit. RN #4 said the CNAs were responsible for notifying the nurse when a resident refused a shower. RN #4 said she was not aware that Resident #1 refused showers. RN #4 said Resident #11 had a history of refusing showers and is quite particular. RN #4 said Resident #11 preferred certain staff members to assist her with showers. The DON was interviewed on 10/19/23 at 1:19 p.m. The DON said the bath aides were responsible for assisting residents with showers. The DON said if a bath aide was not scheduled the CNAs were responsible for assisting residents with showers. The DON said the CNAs should attempt to encourage residents to shower three times prior to documenting the refusal. The DON said Resident #1 refused showers frequently. The DON said Resident #1 needed a lot of convincing to shower and preferred certain staff members. The DON said the residents care plan needed to be updated to include Resident #1's shower refusals and ways to encourage Resident #1 to shower. The DON said Resident #1 often had body odor. The DON said Resident #11 refused showers occasionally. The DON said Resident #11 preferred certain staff members to help her shower. The DON said Resident #11 often had body odor. The DON said Resident #11 responded well to positive reinforcement. The DON said Resident #11's care plan needed to be updated. The DON said the MDS documentation changed on 10/1/23. The DON said the CNAs could have been documenting showers incorrectly as there were a lot of changes. The DON acknowledged that CNA #8 said she did not provide Resident #1 a shower on 10/16/23, despite it being documented in the resident's medical record. The DON said she would provide education to the CNAs on proper shower documentation with the new changes that were implemented.

Based on interviews and record review, the facility failed to ensure one (#62) of one resident reviewed for verbal abuse out of 32 sample residents were kept free from abuse. Specifically, the facility failed to ensure Resident #62 was kept free from verbal abuse and threats by a staff member. Findings include: I. Facility policy and procedure The Abuse policy and procedure, undated, was provided by the nursing home administrator (NHA) on 10/16/23 at 10:30 a.m. It revealed, in pertinent part, (Facility) does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents, volunteers, staff of other agencies serving the resident, family members, legal guardians, sponsors, friends, or any other individuals. Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Resident abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment of a resident resulting in physical harm or pain, mental anguish, deprivation of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. Resident abuse may be verbal, sexual, physical, involuntary seclusion, mental abuse, neglect and/or misappropriation of resident property. Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm, saying things to frighten a resident, such as telling a resident that he/she will never be able to see his/her family again. II. Resident #62 status Resident #62, age 80, was admitted and discharged on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included dementia. According to the 10/4/23 admission nursing notes, the resident had cognitive impairment related to a diagnosis of dementia. The resident required supervision with all activities of daily living. A. Record review The 10/4/23 abuse investigation documented that at 6:00 p.m., registered nurse (RN) #5 received a report from the nurse from the previous shift. Resident #62 was sitting in a chair in the lobby, waiting for his son to come pick him up. RN #5 got into a verbal argument with Resident #62 and began threatening and yelling at the resident, saying I ' m calling the police and you may not live until the police get here. RN #5 was removed from contact with Resident #62 and notified the director of nursing (DON). Licensed practical nurse (LPN) #1, who was interviewed on 10/4/23, said she had her medication cart down in the lobby to keep an eye on Resident #62, who was upset with being admitted to the facility. She said she was waiting for his son to arrive to take him home. Resident #62 was sitting quietly in the recliner chair. She said RN #5 entered the facility for his shift and she informed him why they were in the lobby. She began to give him a report of the day, when he started complaining that he did not need to put up with this guy all night long. She said Resident #62 got upset and said, I can hear what you are saying, I know you are talking about me. She said RN #5 responded back to Resident #62 and said, You ' re right, we are (expletive) talking about you. Not only that, I ' m going to call the police on you. Yeah, you want to (expletive) hit me man, go ahead and hit me. I ' m calling the police and you may not live until the police get here! LPN #1 said she immediately told RN #5 to leave the area and get away from Resident #62. She said he continued swearing as he walked down the hallway, in front of other residents. Resident #62 was easily calmed down and forgot the incident by the time his son had arrived. B. Results of the facility's abuse investigation The conclusion of the abuse investigation documented that RN #5 did not interact appropriately and verbally threatened Resident #62, which was confirmed by witnesses and video surveillance. RN #5 was removed from the area, his employment was terminated and his actions reported to the Board of Nursing. III. Staff interviews The NHA and DON were interviewed on 10/19/23 at 1:57 p.m. The DON said that she was called on the night of 10/4/23 when the incident with RN #5 and Resident #62 happened. She said she interviewed the staff on duty and watched back the video surveillance. She said it was clear that RN #5 was yelling at Resident #62 and had threatened him. The NHA said the facility immediately suspended RN #5 and then decided upon a final action of termination. The NHA said the facility was able to substantiate the verbal abuse by RN #5 toward Resident #62.

Based on observations, record review and interviews the facility failed to provide four (#3, #5, #6, #15) of five residents the necessary services to maintain good nutrition, grooming and personal hygiene out of 20 sample residents. Specifically, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) assistance and needed two person assistance, were provided these services to ensure residents appearances were maintained, and the residents were presentable. Resident #3, who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #3 was totally dependent on one person for eating assistance. The facility failed to provide Resident #3 with eating assistance, who had no use of his upper or lower extremities with eating assistance, so he could have a pleasurable eating experience. Resident #3 said, It was one of the few pleasures he had left in his life. The staff frequently brought a meal tray to his room, left it, and did not come back to feed him for 30 to 45 minutes. He said by then the food was cold. He said it was very difficult to smell food sitting there close to him for a long period of time when he was hungry and not be able to eat it without assistance and no help from staff. Cross-reference F725 for insufficent staffing. Resident #5 who had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The facility's failure to provide cares as needed left Resident #5 hair so matted, she did not want to brush it anymore. She became tearful during the survey and stated her daughter wanted her to shave it off. She said, I do not want to shave my hair. Additionally, the facility failed to provide Resident #5 with the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Also, the facility failed to provide Resident #6 with continuous grooming services, as she stated she had concerns of developing skin infections because of her lack of showers that were provided by staff. Resident #6 during the survey had a strong odor that could be smelled from the residents room when entering, and her hair was matted and uncombed. Furthermore, the facility failed to provide Resident #15 with consistent showers since admission, to the point Resident #15 became upset and attempted to wash her own hair even though she has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Cross-reference F725: The facility failed to provide sufficient regular staff and agency staff, to provide care to dependent residents. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL), updated March 2018, was received from the nursing home administrator (NHA) on 2/3/22 at 10:00 a.m. It read in pertinent part: Residents will be provided with services that are appropriate to maintain or improve their activities of daily living. Those residents who are unable to perform these activities will receive services necessary to maintain their nutritional needs, grooming, and personal hygiene. These activities include bathing, dressing assistance with eating. A resident's ability to perform ADLs will be measured with clinical tools including the minimum data set (MDS). The definitions include Independent- resident needs no help or oversight with the activity. Supervision- the resident requires supervision, oversight and cuing to complete the activity, Limited Assistance- Resident involved in activity and receives physical assistance in maneuvering of limbs, Extensive assistance- resident performed part of the activity and staff provided weight bearing support. Total dependence- Full staff performance of an activity with no participation from the resident. II. Resident #3 the facility failed to provide eating assistance A. Resident status Resident #3, under age 70, was admitted on [DATE] According to the January 2022 computerized physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/13/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 15 out of 15. He was totally dependent on two person assistance with bed mobility, transfers, dressing, and personal hygiene. He was totally dependent on one person assistance for eating. B. Resident interview Resident #3 was interviewed in his room on 1/31/22 at 9:53 a.m. He said he has no use of his upper extremities or lower extremities due to his ALS. He said he wears a [CONDITION(S)] (bilevel positive airway pressure, a type of ventilator device that helps with breathing) to help him breathe, but he could at least still eat. He said it was one of the few pleasures he had left in his life. Resident #3 said the staff frequently brought a meal tray to his room, left it, and did not come back to feed him for 30 to 45 minutes. He said by then the food was cold. He said it was very difficult to smell food sitting there close to him for a long period of time when he was hungry and not be able to eat it without assistance and no help from staff. C. Observations and interviews On 2/1/22 the resident was continuously observed from 9:15 a.m. until 9:50 a.m. At 9:18 a.m., certified nurse aide (CNA) #2, brought a tray to the resident's rooms and set it on his bedside table. At 9:35 a.m. registered nurse/unit manager (RN/UM) came into the resident's room. Resident #3 told her he needed someone to feed him. RN/UM said she would find someone. At 9:37 a.m., licensed practical nurse (LPN) #1 brought the resident some medications. She did not offer to assist him with eating, (as he was fully dependent on staff for this task) and left the room. At 9:45 a.m., CNA #1 came into the room. She said she was from an agency, and had never worked this hall before. She said she thought CNA #2 (another CNA) was suppose to feed the resident, but she could not find CNA #2. The resident said he had been waiting over 20 minutes. It had been 27 minutes, at this time. CNA #2 gave Resident #3 a bite of bacon. He said it was cold. She then gave him a sip of coffee, he said it was cold. CNA #1 then took the items to reheat them. At 9:51 a.m., she returned and assisted him to eat his breakfast. This was 33 minutes after the tray had been delivered. CNA #2 was interviewed at 10:06 a.m. She said she was suppose to give feeding assistance Resident #3 with eating. She said the nurse kept pulling her to do other things, and she never got back to assist Resident #3. She said she delivered his tray over a half hour ago (cross-reference F725, sufficient staffing). The director of nursing (DON) and regional clinical director (RCD) were interviewed on 2/3/22 at 10:03 a.m. The DON said the CNAs and other ancillary staff (department heads) passed trays. The CNAs then feed the residents. She said if they did not have time, they should ask the nurse for help. She said it only takes them 10 minutes to pass trays, and then they can assist with feeding. The DON said the residents should not wait more than 10 minutes to be fed. The RCD said the residents who need assistance with feeding should receive their trays last, and then the CNAs could feed them sooner. CNA #4 was interviewed on 2/3/22, at 10:10 a.m. He said meal trays were delivered to the rooms for all residents. He said the dining rooms were not used due to the COVID-19 outbreak. He said the CNAs had an assignment for the hall or residents and they assisted to feed those residents. He said Resident #3, had his tray delivered first before any other trays. He was not sure why he had food first. The activity director (AD) was interviewed on 2/3/22 at 11:30 a.m. She said she did assist deliver meal trays to residents, but did not assist them to eat. She said she cued residents to eat, but had no credentials to physically assist residents with feeding. III. Resident #5 failed to provide eating and grooming assistance A. Resident #5 status Resident #5, age 75, was admitted on [DATE]. According to the February 2022 computerized physician orders, diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 1/13/22 minimum data set (MDS) indicated the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. The resident required extensive, two person assistance with bed mobility, transfers, and grooming, and one person assistance for eating. It indicated the resident was on a mechanically altered diet and had no known weight gain or weight loss over the past six months. B. Resident interview and observation Resident #5 was interviewed on 2/1/22 at 9:50 a.m. She said it was hard for her to eat and no one came to assist with breakfast. She said the staff dropped off her food, leave and did not ask if she needs any additional items or assistance. She said she did not like to ask for additional help because it would take too long for staff to come help. She said she had one or two bed baths since she had been at the facility. She said her hair was such a mess that she did not want staff to brush it anymore. She said her daughter wanted her to just shave it off. She became tearful and said, I do not want to shave my hair, but was unsure what to do with it since it was so matted. During the interview, the resident was observed to have matted, hair and disheveled appearance. C. Observations Certified nurse aide (CNA) #1 was observed passing lunch trays on 2/1/22 at 12:57 p.m. She entered Resident #5's room to give her the lunch tray. Resident #5 asked for a drink. -At 1:05 p.m., CNA #1 returned to Resident #5's room with her drink. She left the drink and did not offer any additional assistance. -At 1:10 p.m., Resident #5 was observed in her room eating her lunch. Her plate was placed on her stomach and she was laying in bed. She was self feeding and food was observed to have fallen on her chest. Resident #5 was coughing during the meal. D. Record review The activities of daily living care plan was last revised on 2/2/22. It indicated the resident required extensive-to-total assistance for activities of daily living. It indicated staff to provide assistance with grooming and personal hygiene in the morning and evening and as needed. It indicated feeding assistance to be provided as needed. It did not indicate bathing preferences. The bathing records were provided by the nursing home administrator (NHA) on 2/2/22 at 5:11 p.m. The records indicated Resident #5 received one bed bath on 1/14/22. No additional documents such as refusals were provided. The shower task list located in the electronic medical record indicated Resident #5 had a preference for a bed bath on Mondays and Wednesdays in the evening. E. Staff interviews CNA #1 was interviewed on 2/1/22 at 12:00 p.m. She said she was an agency staff member. She said she did not know how much assistance Resident #5 required. She said she would sometimes receive a sheet with that information prior to starting her shift but she did not receive one. CNA #3 and CNA #4 were interviewed on 2/3/21 at 9:45 a.m. They said Resident #5 required extensive assistance and use of a Hoyer (mecahnical lift). CNA #3 said Resident #5 required feeding assistance but they will ask her at meal times if she would like assistance. CNA #4 said she liked to try to self feed and would ask for additional help if needed. The director of nursing (DON) and regional clinical director (RCD) were interviewed on 2/3/22 at 10:15 a.m. The DON said CNAs were the staff members that completed showers and baths with the residents. She said if a resident refused a bath it should be reported to the nurse. She said not every refusal was documented. She said Resident #5 had a preference for familiar staff to complete her cares (though this was not documented in her care plan). She said the beautician had not been coming into the building to assist with hair care. The RCD asked the DON if they had tried the use of shower bathing caps and the DON said they did not. CNA #4 was interviewed again on 2/3/22 at 12:45 p.m. He said Resident #5 refused showers and baths. He said she refused to allow her hair to be brushed. He said he would let the nurse know when this happened and then the nurse would document. CNA #5 was interviewed on 2/3/22 at 12:49 p.m. She said she was an agency staff member and was unsure how much assistance Resident #5 required for meals. She said Resident #5 could self feed but needed verbal cues during meals. The DON was interviewed on 2/3/22 at 1:46 p.m. She said Resident #5 required set up assistance with meals. She said she was unsure why the MDS assessment was different. She said she would ask the resident if she would like more assistance. She said she was unsure if the resident had lost weight because she had not had her weight taken since admission. IV. Resident #6 A. Resident status Resident #6, age 68, was admitted on [DATE]. According to February 2022 computerized physicians orders (CPO) the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 12/4/21 minimum data set (MDS) revealed the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She required extensive two person hoyer assistance with bed mobility, transfers, dressing, toilet use and bathing. B. Resident observation and interview Resident #6 was observed in her room on 2/1/22 at 9:45 a.m. There was a strong odor coming from the room. The resident's clothes had a brown substance on them.The resident's hair was matted and uncombed. Resident #6 was interviewed on 2/1/22 at 10:00 a.m. She said she had been at the facility for six weeks and had received two showers during that time. She said she asked for three showers a week and did not even get one. She said she had been asking for a shower for the last five days and had not received one. She said the staff told her it took two people to help her with the shower and they did not have the extra person to help. She said she had folds of skin in her stomach and that area needed to be cleaned daily. She said she was concerned about developing an infection in those areas because they were not cleaned regularly. She said she could not reach those areas and was dependent on the staff to do it for her. C. Record review Care plan dated 2/3/22 indicated Resident #6 had ADL self care deficit, limited mobility, limited range of motion (ROM) and shortness of breath (SOB) and poor activity tolerance. The resident required limited to extensive assistance with ADLs. The resident required two person hoyer assistance with transfers. Interventions include, offer and provide assistance with transfers, bathing, incontinence care and dressing. The January 2022 shower record for Resident #6 revealed the following: The resident received a shower on 1/16/22. For the rest of the month it was not documented that she received a shower. It was not documented that the resident refused a shower. V. Resident #15 A. Resident status Resident #15, under age 65, was admitted to the facility on [DATE]. According to the February 2022 computerized physicians orders (CPO) the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 11/13/21 minimum data set (MDS) revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 15 out of 15. She required limited assistance with transfers, toilet use, and one person physical assistance with bathing. B. Interview Resident #15 was interviewed on 2/1/22 at 2:10 p.m. She said it took two weeks of asking for a shower to finally get one. She said she got out of isolation for COVID on 1/14/22. She said she had one shower while she was in isolation. She said she was scheduled for a shower on Sunday 1/30/22 and never got one. She said she waited three hours for the CNA to come to her room and when she did show up, she told the resident that there was not enough staff for her to receive a shower that day. The CNA said she would give the resident a shower the next day. Resident #15 said this made her upset and she washed her own hair in the sink in her room and gave herself a sponge bath. She said this was difficult to do due to her limited mobility. She said a CNA came to help her with a shower the following day and she told the CNA she had done it herself. C. Record review Care plan dated 2/4/22 indicated Resident #15 had impaired balance, limited mobility and musculoskeletal impairment. The resident required one person assistance with bathing two times per week. The January 2022 shower record for Resident #15 revealed the following: the resident received a shower on 1/10/22. There were no other documented showers for this resident for the rest of the month. It was not documented that the resident refused a shower. D. Staff interviews The assistant director of nursing (ADON) was interviewed on 2/1/22 at 10:05 a.m. She said the facility had enough available staff to make sure the residents were getting their showers. She said Resident #6 and Resident #15 required assistance with showers. She said many residents refused their showers and she would provide the list of those residents. She said she would find out how often these residents were actually receiving showers. -This list of residents who refused their showers or a list of how often the residents were receiving showers was not provided before exit on 2/3/22. CNA #6 was interviewed on 2/3/22 at 10:45 a.m. She said she usually worked at the Oak hall and it was the busiest of all the units. She said many residents in the hall needed assistance with showers but she did not have the time to help them due to the needs of the other residents and she worked this unit by herself. She said Resident #6 and Resident #15 required assistance with bathing. She said she was not able to help Resident #6 and Resident #15 with showers due to just trying to keep up with the call lights. CNA #4 was interviewed on 2/3/22 at 2:30 p.m. He said he could not get his showers completed on his shift due to lack of staff to help. He said he did not get a break most of the time either. He said there was one particular resident who took up most of his time during his shift and it was difficult to get to other residents.

Based on observations, record review and interviews, the facility failed to provide care in manner which promoted dignity and respect for one resident (#48) of two reviewed out of 32 sample residents. Resident #48 was dependent on staff for toileting. Resident #48 was left soiled with bodily fluids for over 15 hours when her bed broke and staff failed to perform incontinence care, a human right. The delay in care left the Resident #48 feeling anxious (requiring a breathing treatment), distressed, fearful and undignified. She had to eat breakfast and lunch while sitting in urine socked brief and sheets with fecal matter (see resident interview below). The resident said she felt like she was treated like an animal by the staff the way she had been left. Cross-reference citations: F600 failure to prevent neglect; and, F677 Failure to provide activities of daily living for dependent residents. Findings include: I. Facility policy The Resident Rights Policy, revised December 2016, was provided by the nursing home administrator (NHA) via email on 5/5/21 at 10:39 p.m. It read in pertinent part, Employees shall treat all residents with kindness, respect and dignity. Federal and state laws guarantee certain basic rights to the residents of this facility. The rights include the resident's right to: a dignified existence and be free from abuse, neglect, misappropriation of property and exploitation. II. Resident #48 A. Resident status Resident #48, age 79, was admitted to the facility on [DATE]. According to the May 2021 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 4/28/21 minimum data set (MDS), the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was totally dependent on the assistance of two staff for toileting and required extensive assistance from two staff to perform bed mobility and transfers. B. Resident interview and observation Resident #48 was interviewed on 5/3/21 at 11:48 a.m. Said the bed had been broken since last evening (5/2/21) around 6:00 p.m., just after shift change. The resident said she was not able to get up to use a commode; instead staff would lay her bed flat in order to turn her from side to side, cleaning her up and then changing her. She said that because the bed was broken this did not occur since yesterday just before shift change. She said she had been laying in her urine and feces in the wet bed since yesterday evening, cross-reference F600. She said she asked several times if they could move her to a new bed to get her cleaned up but was told the facility did not have an extra bed. The resident said she started to urinate soon after the bed broke and continued to urinate through the night without being cleaned up. The resident said she also had a bowel movement last night that needed to be cleaned up. The DON was interviewed on 5/3/21 at 12:44 p.m. The DON said staff planned to see if the reset button would correct the bed malfunction if that did not work. The staff would change the resident while up in the Hoyer sling. Staff found an appropriate Hoyer sling to fit the resident, with an open bottom and planned to clean and change Resident #48, as a backup. Incontinent care was to occur as soon as the resident finished eating her lunch. On 5/3/21 at 1:10 p.m., Resident #48's incontinent care was observed. Three CNAs #6, #4 and #7 were observed completing resident care. The DON was also present. Staff explained to the resident they were going to put her in a Hoyer sling and raise her off the bed, so they could clean her and change her incontinent brief and bed linens. CNA #7 asked the resident if she just wanted to get up into her wheelchair and take a shower. Resident #48 said no, I just want to get changed, I just want to do one thing at a time, I just want to get cleaned up. CNA #7 assisted the resident to lean forward as much as possible, while leaning the resident forward the other two CNAs placed the Hoyer sling behind the resident behind the resident's back and pushed the sling down behind the resident as much as possible. The other two CNAs pulled the resident side to side while the third CNA pushed the leg straps of the Hoyer sling under the resident's buttocks and leg as much as possible then repeated the process on the other side to the resident. Because of the resident's size and inability to move freely in the bed this process took several attempts. Once staff got as much of the Hoyer sling under the resident as possible, they hooked the straps up to the Hoyer sling. The resident began to yell, You are hurting me; the straps are digging into my leg. Staff released the strap and went to get a towel to place in between the resident's leg and strap of the sling then reconnected to sling strap to the lift. Staff told Resident #48 they would lift her off the bed and readjust the straps to pull them into place as they raised her off the bed. Resident #48 said, You're going to change me up in the air? Staff tried to reassure the resident, by re-explaining how they were going to get her cleaned up. The resident was getting distressed; expressing fear of being dropped and fear of being injured because the sling was not placed correctly. Staff continued to offer reassurance throughout the process. As staff lifted the resident off the bed they readjusted the Hoyer sling taking several attempts to get the sling correctly placed in order to support the resident in the sling. The resident was getting more anxious yelling again, your hurting me, the strap is cutting into my leg. Staff told the resident you ' re doing good, were trying to be quick. The resident responded by saying you tell me it's going to be a few minutes and it ends up being more like 15 or 20 minutes, this is painful you need to put me back down. Staff continued to change the resident. The resident had feces up her back to her waist and upfront in her vaginal area. The CNAs were able to clean most of the feces from the resident's back and some from the vaginal area. Staff had trouble getting the incontinent brief out from between the sling and the resident. The resident smelled strongly of urine and feces. The brief was heavily soaked with dark yellow urine and feces, which dripped down onto the side of the bed and onto the floor as staff continued to change the resident on the mechanic lift. The DON had to go set scissors so staff could cut the brief in pieces to remove as much as possible before lowering the resident onto the clean bedding. The resident started to complain of being short of breath. As staff finished clean and changing Resident #48, the resident became excitable, her voice high pitched and panicky. The resident said, I need more oxygen. Staff checked placement of the resident nasal cannula oxygen tubing and reassured the resident her oxygen was operating. The resident replied no, I need my treatment, get my treatment. Staff grabbed the resident sheet from the top of the bed and pulled the resident up in the bed in an attempt to reposition the resident in a more up right position to ease her breathing. Staff pulled the resident to the top of the bed but were not able to use the draw sheet properly to get the resident up in the bed because of the elevated head of the bed. Registered nurse (RN) #2 had come into the room to complete a skin assessment. RN #2 offered the resident an [MEDICATION(S)] rescue inhaler. The resident said she never used the rescue inhaler but would try it. After using the inhaler, the resident said she was still experiencing shortness of breath and said, I need another treatment, I can't breathe. RN #2 encouraged the resident to calm and give the inhaler time to take effect, explaining it takes a few minutes to work and that she had just had her morning nebulizer treatment. The resident did not want to wait any longer and felt she needed PRN (as needed) nebulizer treatment. RN #2 administered the nebulizer treatment and the resident started to calm. Resident #48 was interviewed again on 5/3/21 at 3:20 p.m. She said her bed had been fixed and she demonstrated that she was able to use the bed remote to adjust her position. She said that she understood that sometimes things can happen, but I am not not an animal; I am a human being. She said that she knew that sitting in stool and urine can be dangerous because she was left unchanged for an extended period of time previously (not at the current facility) and it resulted in her having an infection and going to the hospital. She said she feared developing another infection. III. Record review The resident care plan, updated 2/20/21, included that the resident was totally dependent on staff for toileting and transfer. The resident required two to four staff to assist with a mechanical Hoyer to complete transfers. The resident's psychosocial well-being care plan, revised on 4/29/21, included that has a potential psychosocial well-being problem related to past experiences in a skilled nursing facility and has concerns about receiving care. Per her report, at a previous facility, staff did not respond to her requests for assistance, so she learned to get her needs met by yelling out rather than using her call light. Interventions included to allow the resident time to answer questions and to verbalize feelings, perceptions, and fears as needed or when she appears distressed. Additional intervention included that staff were to anticipate and meet resident's needs to reassure her that she is taken care of. V. Staff interviews The NHA was interviewed on 5/5/21 at 4:11 p.m. She said prolonged wait for care could have a negative psychological impact for a resident. She said that looking at the bigger picture of what an outcome could be for a resident was important. She said it was important to have identified how Resident#48 was feeling as she waited for care and had to be changed while in a Hoyer sling. The DON was interviewed on 5/5/21 at 5:36 p.m. She said that significant delays in care could result in a resident having feelings of anxiety, pain, psychosocial harm, helplessness and discomfort. She said the resident eating her meal while soiled could result in her feeling undignified. She acknowledged the resident felt anxious at the time care was performed in the Hoyer sling. She said generally, extended wait time for incontinence care could lead to a resident feeling embarrassed and frustrated. She said that she was concerned about the resident's skin integrity since she had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said that staff offered to change the resident prior to eating her lunch but that the resident had elected to eat before being changed. -However, during the DON interview at 12:44 p.m. (see above) she indicated incontience care would be provided to the resident after she ate her lunch.

Based on observation record review and interviews, the facility failed to ensure all residents were free from abuse, neglect, and exploitation, for one (#48) of two residents out of 32 sample residents. Resident #48 was dependent on staff for toileting. The facility failed to implement all possible interventions to prevent a neglectful situation where Resident #48 was left soiled with bodily fluids for over 15 hours when her bed broke and staff failed to perform incontinence care, resulting in wound injuries to the skin (see physician's wound care note 5/6/21), pain and short-term emotional distress. Cross-reference citations: F550 failure to ensure a resident was treated in a dignified manner; F677 failure to provide timely incontinent care to a dependent resident; F689 failure to follow up on malfunctioning equipment in order to prevent a hazardous condition; F842 failure to ensure the resident record accurately documented skin injuries; and, F610 failure to conduct a complete and thorough investigation of an allegation of neglect. Findings include: I. Facility policy and procedure The Abuse Prevention Program policy, dated December 2016, was provided by the nursing home administrator (NHA) on 5/3/21 at 1:19 p.m. It read in pertinent part: Our residents have the right to be free from abuse, neglect .As a part of the resident abuse prevention program, the administrator will: Protect our resident form abuse by anyone including but not necessarily limited to: faculty staff, other residents .Implement measures to address factors that may lead to abusive situations. Identify and assess all possible incidents of abuse. Establish and implement a review and analysis of abuse incidents and implement changes to prevent future occurrences of abuse. Involve the resident council in monitoring and evaluating the facility's abuse prevention program. The Resident Rights and Dignity policy, dated March 2018, was provided by the NHA on 5/4/21 at 10:10 a.m. It read in pertinent part: Along with staff and management, the physician will help identify situations that might constitute or could be constructed as neglect; for example inappropriate management of problematic behavior, recurrent failure to provide incontinent care. -The staff with the physician's input, as needed will investigate alleged abuse and neglect to clarify what happened and identify possible causes. -The physician will provide adequate documentation regarding significant negative outcomes that have resulted from a resident's underlying medical illness or conditions, despite appropriate care. II. Facility summary Resident #48 was left in a soiled incontinent brief and bed on 5/2/21 from approximately 7:00 p.m. to 5/3/21 at 1:10 p.m. The resident said her bed was broken on the evening of 5/2/21 shortly after the change of shift at approximately 6:00 p.m. The resident was incontinent of both bowel and bladder and continued to have incontinent episodes throughout the night without being cleaned and changed. Due to the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was completely dependent on staff for toileting and transfers; and required a bariatric sized bed and other essential equipment for her condition. -The facility did not have a spare bed for the resident's use. Evening/night staff did not alert the on call supervisor for guidance on how to meet the resident's care needs; after discovering the resident's bed was broken and they were not able to flatten the bed to effectively clean and change the resident's soiled brief and bedding. Per care plan interventions, the resident needed to be flat in bed during bed mobility for incontinent care and repositioning, to preserve skin integrity. The resident was not to be positioned in the bed with the head of the bed elevated to prevent injuries to the skin. The resident's broken bed and incontinent condition was reported to the day shift staff upon shift change at 6:00 a.m. on 5/3/21. Despite this notification, the resident was still not changed until hours later in the shift at 1:00 p.m. The broken bed was not reported to the director of nursing (DON) until 9:00 a.m. on 5/3/21, when she arrived at the facility. The resident continued to sit in soiled briefs and bedding while the interdisciplinary team considered a remedy. -The facility did not have the operators manual for the resident's bed and were not aware the bed had a manual crank to lower the head of the bed in the event of equipment or electrical failure. -The facility's maintenance staff were not working on 5/3/21, and there was no confirmed contact with the medical equipment vendor until 5/3/21 at 12:05 p.m. when the vendor took the facility's urgent request for bed repair so they could change the resident. It was not until 1:10 p.m. when the clinical team came up with a method to clean and change the resident in the broken bed. The facility was able to locate a fitting mesh Hoyer (mechanical lift) sling with an opening at the bottom to enable staff to clean the resident's genital area. -The staff informed the resident of the process and assisted the resident to lean from side-to-side and they pushed the Hoyer sling under the resident re-positioning the sling little by little, as they started to raise the resident up off the bed in the lift. This process caused the resident emotional distress. The resident became anxious, she was fearful of being dropped, injured and complained of pain during care. The sling used was not the resident's usual sling and she complained of pain and pinching at the inner thighs where the sling cross under her thigh and up over the inner thigh to support the resident's legs in the mechanical lift. The resident became fearful that staff would cause her injury because they were unable to position the sling properly to fully support the resident's body until the staff lifted her off the bed and readjusted the Hoyer sling as she was up in the air. The resident was so anxious about the procedure. Her slumped posture and positioning during incontinent care caused the resident to feel short of breath. The resident complained that she needed more oxygen. The resident said several times, I'm having trouble breathing, her breaths increased slightly and her breathing was labored. The resident repeatedly requested an unscheduled nebulizer treatment. Once the resident was changed and lowered back to the bed the nurse administered a dosed rescue inhaler followed by a nebulizer treatment because the resident said the rescue inhaler was ineffective. -A skin assessment later that afternoon revealed the resident had skin injuries to the back of the left upper thigh, right buttocks, and abdominal fold, (see record review, resident observations, interviews and post event record review for details). -The facility failed to provide any staff education regarding neglect before the survey was exited on 5/6/21. III. Resident #48 A. Resident status Resident #48, age 79, was admitted to the facility on [DATE]. According to the May 2021 computerized physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 4/28/21 minimum data set (MDS), the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident was fully dependent on the assistance of two staff for toileting and all transfers; staff performed all of the effort on this task and the resident was unable to perform any effort to complete the toileting activity. The resident was dependent on staff needing extensive assistance from two staff for bed mobility, roll in from left to right, bathing, and dressing. The resident was always incontinent of both bowel and bladder. The resident had no open wounds at the time of the assessment, but was at risk for developing pressure ulcers. The resident was on diuretics and oxygen therapy. B. Record review Resident #48's comprehensive care plan revision 2/21/21, revealed the following care focus at the time of the occurrence: Care focus activities of daily living (ADL): Resident #48 has ADL and self-care performance deficit related to [CONDITION(S)], and limited physical mobility. Interventions included: -Resident #48 is totally dependent on staff for toilet use; -Resident #48 requires two staff participation to reposition and turn in bed; -Resident #48 requires skin inspection during ADL care, observe for redness, open areas; scratches, cuts, bruises and report changes to the nurse; -Resident #48 is totally dependent on staff for repositioning and turning in bed; and, -Resident #48 requires the use of a mechanical aid (Hoyer lift) for transfers with 2-4 persons required at all times when using the Hoyer lift. Care focus for Skin integrity: Resident #48 has potential for alteration in skin injury development related to limited physical mobility, obesity, [CONDITION(S)]. Interventions included: -Antifungal powder to abdominal folds, as ordered; Barrier cream, as ordered; -Educate the resident as to causes of skin breakdown including transfer/positioning requirements, importance of taking care during ambulation/mobility, good nutrition and frequent repositioning; -Needs two (2) person assistance to turn/reposition as frequent as needed or as requested; and, -Requires the bed as flat as she can tolerate to reduce shear and to be repositioned with two people using a draw sheet, as frequently as possible. Care focus for psychosocial well being: Resident #48 has a potential psychosocial well-being problem related to past experiences in a nursing facility and concerns about receiving care. Per Resident #48's report, at a previous facility, staff did not respond to her requests for assistance, so she learned to get her needs met by yelling out rather than using her call light. Care focus for respiratory failure: Resident #48 has altered respiratory status and difficulty breathing related to diagnosis. Interventions included: -Elevate head of bed as the resident can tolerate; -Monitor and document changes in orientation, increased restlessness, anxiety, and air hunger; -Position resident to facilitate ventilation and perfusion matching (proper air exchange), using a fowler's position (straight and un-slouched) upright, high-sitting position whenever possible. The 4/27/21 weekly assessment nurse note documented the resident was oriented to self, time, place and situation; had consistent and reasonable decision-making skills, with only occasional short and long-term memory difficulty. The resident had no signs of symptoms of [CONDITION(S)] and other than making negative comments/statements; the resident had no other mood or behavioral expressions. The resident was frequently short of breath and was on continuous oxygen. The resident was free of any open areas or skin tears at the time of the assessment. Resident #48 skin assessment task record documented the resident had no open areas and only redness on 4/28/21 and 5/2/21. A medical vendor communication note, dated 5/3/21, was provided by the NHA on 5/3/21 at 4:53 p.m. revealed a service call for repair was set up on 5/3/21 at 12:05 p.m. The repairman arrived and fixed the resident's bed on 5/3/21 at 2:38 p.m. The Invacare (IVC) Bariatric Bed manual, dated 2016, was provided by the NHA on 5/5 /21 at 2:10 p.m. It read in pertinent part: General guidelines: contact a qualified technician for repair. -Emergency crank: Due to a power outage or an electronic malfunction an emergency crank is provided. Instruction for use of the manual crank: The manual crank connector is located under the bed. Locate the exposed shaft and according to the function you want to perform attach the emergency crank to the monitor shaft end of the head section or the monitor shaft of the foot end section; crank counter clockwise or counter clockwise to lower the bed end. 2. Observations and interviews On 5/3/21 at 12:00 p.m., Resident #48 was observed in bed. The head of the bed was fully elevated at approximately 90 degrees. The resident was heavily soiled with urine and feces, as evidenced by the wet and yellow stained sheets and a strong smell of urine and feces. The flat sheet the resident was lying on did not fully cover the mattress and was only partially under her buttocks and not under her legs. The top sheet was balled up between the resident's legs. Resident #48 was interviewed on 5/3/21 at 11:48 p.m. Resident #48 said the bed she was in had been broken since last evening (5/2/21) around 6:00 p.m., just after shift change. The resident said she was not able to get up to use a commode; instead staff would lay her bed flat in order to turn her from side to side to remove soiled items, clean and change her. Because the bed was broken this did not occur, at any point after the bed broke. Resident #48 said she had been laying in her urine and feces in the wet bed since yesterday evening and she was feeling uncomfortable. She just wanted for staff to clean her up. Resident #48 said she asked the night CNA's and nurse on duty, several times, if they could move her to a new bed to get her cleaned up but was told the facility did not have an extra bed. The The resident said she started to urinate soon after the bed broke and continued to urinate through the night without being cleaned up. The resident said she also had a bowel movement last night that still needed to be cleaned up. CNA #6 and Resident #48 were interviewed on 5/3/21 at 12:00 p.m. CNA #6 said she was working with Resident #48 yesterday (5/32/21) on the day shift. Just before leaving shift around 5:00 p.m. CNA #6 assisted another CNA to clean and change Resident #48; she had no open wounds or pressure ulcers, at that time. Resident #48 then said to CNA #6, the bed broke after you left around 6:00 p.m., and I haven't been changed since you left. CNA #6 said she was informed of the resident's broken bed when she arrived for shift this morning (5/3/21). The CNA was unaware of the plan to get the resident changed and was waiting for direction. CNA #6 was unaware if the resident's bed had a manual crank option to adjust the angle of the foot and head of the resident's bed. Registered nurse (RN) #2 was interviewed on 5/3/21 at 12:02 p.m. RN #2 said she was informed the resident needed incontinent care but the bed was broken and the resident could not be laid flat to clean her up. RN #2 said this information was provided at 6:00 a.m., during shift change. RN #2 did not know what the CNAs were doing to get the resident changed, but said the director of nursing (DON) was working with the CNAs on a plan. RN #2 said the facility had requested repair service from the medical equipment vendor, but it was going to be a couple of hours before the repair person could get to the facility. RN #2 was not sure what time the repair person was expected. RN #2 was unaware if the resident's bed had a manual crank option to adjust the angle of the foot and head of the resident's bed. The DON was interviewed on 5/3/21 at 12:10 p.m. The DON said she had received a report that the resident's bed was broken and she needed to be changed. The DON did not get this report until 9:00 a.m. this morning when she arrived to the facility. The DON said she was not informed the bed broke last night and was under the impression the bed had only been broken for approximately two hours before being notified of the broken bed. The DON said the facility maintenance director was off today so the medical equipment vendor had been notified and a service call was requested, however, it would be a couple of hours before the repair person would arrive. The DON was unaware if the bed had a manual override to adjust the bed, she said she would contact the bed vendor for more information. In the meantime, the DON was working with the interdisciplinary team (IDT) on a solution to get the resident changed. The DON was interviewed on 5/3/21 at 12:44 p.m. The DON said she talked to the medical equipment vendor and was informed the resident bed had a reset button. Staff planned to see if the reset button would correct the bed malfunction if that did not work. The staff would change the resident while up in the Hoyer sling. Staff found an appropriate Hoyer sling to fit the resident, with an open bottom and planned to clean and change Resident #48, as a backup. Incontinent care was to occur as soon as the resident finished eating her lunch. The DON said she started an all staff education of the requirement to immediately notify management of broken and equipment failures and how to utilize the bed's manual function when an electrical malfunction occurred. On 5/3/21 at 1:10 p.m., Resident #48's incontinent care was observed. Three CNAs #6, #4 and #7 were observed completing resident care. The DON was also present. CNA #4 tried to reset the resident bed with a reset button under the frame of the bed, but was unable to get the bed to reset. Staff were still not aware of the bed's manual crank option to adjust the angle of the head and foot of the bed. Staff explained to the resident they were going to put her in a Hoyer sling and raise her off the bed, so they could clean her and change her incontinent brief and bed linens. CNA #7 asked the resident if she just wanted to get up into her wheelchair and take a shower. Resident #48 said no, I just want to get changed, I just want to do one thing at a time, I just want to get cleaned up. CNA #7 assisted the resident to lean forward as much as possible, while leaning the resident forward the other two CNAs placed the Hoyer sling behind the resident behind the resident's back and pushed the sling down behind the resident as much as possible. The other two CNAs pulled the resident side to side while the third CNA pushed the leg straps of the Hoyer sling under the resident's buttocks and leg as much as possible then repeated the process on the other side to the resident. Because of the resident's size and inability to move freely in the bed this process took several attempts. Once staff got as much of the Hoyer sling under the resident as possible, they hooked the straps up to the Hoyer sling. The resident began to yell, You are hurting me; the straps are digging into my leg. Staff released the strap and went to get a towel to place in-between the resident's leg and strap of the sling then reconnected to sling strap to the lift. Staff told Resident #48 they would lift her off the bed and readjust the straps to pull them into place as they raised her off the bed. Resident #48 said, You're going to change me up in the air? Staff tried to reassure the resident, by re-explaining how they were going to get her cleaned up. The resident was getting distressed; expressing fear of being dropped and fear of being injured because the sling was not placed correctly. Staff continued to offer reassurance throughout the process. As staff lifted the resident off the bed they readjusted the Hoyer sling taking several attempts to get the sling correctly placed in order to support the resident in the sling. The resident was getting more anxious yelling again, you're hurting me, the strap is cutting into my leg. Staff told the resident you ' re doing good, were trying to be quick. The resident responded by saying you tell me it's going to be a few minutes and it ends up being more like 15 or 20 minutes, this is painful you need to put me back down. Staff continued to change the resident. The resident had feces up her back to her waist and upfront in her vaginal area. The CNAs were able to clean most of the feces from the resident's back and some from the vaginal area. Staff had trouble getting the incontinent brief out from between the sling and the resident. The resident smelled strongly of urine and feces. The brief was heavily soaked with dark yellow urine and feces, which dripped down onto the side of the bed and onto the floor as staff continued to change the resident on the mechanic lift. The DON had to go set scissors so staff could cut the brief in pieces to remove as much as possible before lowering the resident onto the clean bedding. The resident started to complain of being short of breath. Once the resident was back on the bed the staff rolled her side to side to remove the rest of the soiled brief. At this point the resident was slouched down in the bed and no longer sitting up straight in the recommended Fowler's position (seated semi-position 45 to 60 degrees) to facilitate better breathing. Staff still had to clean a lot of feces from the resident's skin folds and vaginal area. Staff had to replace the clean brief just placed under the resident as it immediately became soaked with urine once the resident was placed on the clean bedding. RN #2 entered the resident's room to attempt a skin assessment, but was not able to see the resident's buttocks because the resident bed was still broken and the resident was in a slouched position with the head of the bed still at a 90-degree angle. The CNAs had a hard time turning the resident enough to provide a full unobstructed view of the resident's buttocks, thighs and coccyx area for the RN to conduct a skin assessment. RN #2 said she was unable to fully assess the resident and would complete a thorough assessment once the resident bed was repaired and the resident could lay flat for the assessment. As staff finished clean and changing Resident #48, the resident became excitable, her voice high pitched and panicky. The resident said, I need more oxygen. Staff checked placement of the resident nasal cannula oxygen tubing and reassured the resident her oxygen was operating. The resident replied no, I need my treatment, get my treatment. Staff grabbed the resident sheet from the top of the bed and pulled the resident up in the bed in an attempt to reposition the resident in a more up right position to ease her breathing. Staff pulled the resident to the top of the bed but were not able to use the draw sheet properly to get the resident up in the bed because of the elevated head of the bed. RN #2 offered the resident an [MEDICATION(S)] rescue inhaler. The resident said she never used the rescue inhaler but would try it. After using the inhaler, the resident said she was still experiencing shortness of breath and said, I need another treatment, I can't breathe. RN #2 encouraged the resident to calm and give the inhaler time to take effect, explaining it takes a few minutes to work and that she had just had her morning nebulizer treatment. The resident did not want to wait any longer and felt she needed PRN (as needed) nebulizer treatment. RN #2 administered the nebulizer treatment and the resident started to calm. The DON was interviewed on 5/3/21 at 1:45 p.m. The DON said once the bed was repaired the nurse would complete a full skin assessment. On 5/3/21 at 2:38 p.m., the medical equipment vendor repair person arrived. The remote was replaced and the bed was fixed and in operation order. On 5/3/21 at 3:32 p.m., CNA #4, #6 and #7 were observed providing incontinent care to the resident. The resident's bed was working properly and the staff were able to flatten the resident's bed and provide care per the intervention document in the resident's comprehensive care plan. RN #2 completed a skin assessment. RN #2 confirmed the resident had four - one centimeter (cm) long slits and a one cm by one cm open area the upper left thigh open wounds with a small amount of bright red drainage from the wounds, and a rash on the inner left thigh. The resident had observable redness in between her thighs on the left leg, along a skin fold along the back at the waist on the right side, along a skin fold at the back of the middle of the left thigh, under the skin overlapping her abdomen, and on the resident lower left buttocks. RN #2 applied barrier cream the resident buttocks, coccyx area, thighs front and back. RN #2 said she observed Resident #48 skin on 5/2/21 and again confirmed the resident did not have any open area on her skin during the (5/2/21) observation. On 5/5/21 at 12:00 p.m., the RN wound nurse (RNWN) was observed completing a skin assessment for Resident #48. RNWN said Resident #48 had moisture related wounds; there were four superficial slits in the skin and a one cm by on cm open area on the back of the upper thigh. RNWN said staff will apply barrier cream to the wound until orders were obtained from the wound physician to ensure appropriate treatment. 3. Post occurrence record review Physician's wound care noted dated 5/6/21 read in part: Wound Assessment: Presence of new wounds. -Wound #1: Right buttock lower is a stage two-pressure injury, pressure ulcer and has received a status of Not Healed. Initial wound encounter measurements are one (1) CM length by x 1.5 CM width by 0.1 CM in depth . -Wound #2: Left lower buttock/thigh is a stage two-pressure injury, pressure ulcer and has received a status of not healed. Initial wound encounter measurements are six (6) CM in length by 10 CM width x 0.2 CM depth . -Wound #3: Left, medial thigh fold is a moisture associated with skin damage and has received a status of not healed. Initial wound encounter measurements are 13 CM length by 10 CM width by x 0.1 CM depth . Wound #4: Left lateral pannus (abdominal overlap) is a moisture associated with skin damage and has received a status of not healed. Initial wound encounter measurements are three (3) CM length by 13 CM width x 0.1CM depth . -Assessment: Healing is expected to be delayed due to identified factor(s): diabetic complicating factors, impaired mobility, incontinence, inevitable effect of aging, and medications that inhibit optimal wound healing. 4. Other Interviews The NHA was interviewed on 5/3/21 at 1:05 p.m. She said she had placed two calls to the medical equipment service provider and was unable to get through to a live operator so he had to entered a formal work order into the computerized system in order to schedule a repair session. That work order was placed on 5/3/21 at 12:05 p.m. The DON was interviewed on 5/5/21 at 5:20 p.m. The DON said she would expect a resident who had been sitting in the same position in a solid bed for an extended time to have some emotional and physical pain. Timely care was very important to address potential negative effects of a dependent resident being left in soiled briefs for extended periods of time. The first concern would be development of skin injury followed by psychosocial impairments. Resident #48 was had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . CNA #9 was interviewed on 5/6/21 at 10:41 a.m. CNA #9 worked the evening/night shift from 5/2/21 6:00 p.m. to 5/3/21 6:00 a.m. CNA #9 said he was not able to provide care to the resident due to the resident preference for certain caregivers. He had not been in the resident's room until 4:15 a.m. during last rounds; it was at that time when he was informed the resident's bed was broken and the head of the bed was stuck in a fully upright position. CNA #9 notified RN #1 who was the nurse on duty. The nurse checked the plug connection but the bed was still not operating correctly and the head of the bed would not lower. CNA #9 was under the impression that one of the other female CNAs on duty provided as much care as possible for the resident throughout the shift, but had no direct observation. CNA #9 said the nursing staff were not trained to address failed equipment. CNA #5 was interviewed on 5/6/21 at 10:46 a.m. CNA #5 worked the evening/night shift from 5/2/21 6:00 p.m. to 5/3/21 6:00 a.m. CNA #5 went to check on the resident at 12:15 a.m. and discovered the resident was soiled with urine as evidenced by the blue wetness indicator on the front outer surface of the incontinent brief. CNA #5 discovered the bed was broken and the head of the bed was stuck at a 90-degree angle. CNA #5 notified the nurse on duty and was under the impression that the nurse was going to contact maintenance. CNA #5 said she was unable to complete incontinence care for the resident due to the broken bed, but she did check on the resident throughout the night. The resident was sleeping on and off through the night. RN #1 was interviewed on 5/6/21 at 10:58 a.m. RN #1 worked the evening/night shift from 5/2/21 6:00 p.m. to 5/3/21 6:00 a.m. RN #1 became aware that the resident's bed was no longer working around 12:00 a.m. on 5/3/21. RN #1 said that she had went into Resident #48's room at approximately 12:00 a.m., to assist CNA #5 with the resident's care, but the head of the bed was stuck in the upright position. Resident #48 was wet and needed to be cleaned and changed, but they were unable to perform incontinent care. RN #1 thought it was terrible to leave the resident wet throughout the night, normally we would change Resident #48 every couple of hours due to the frequency of her incontinence. RN #1 did not think it was an immediate concern; so the RN decided to wait until the day shift arrived and let the oncoming morning shift determine the best way to change the resident. When the day shift arrived, RN #1 gave a report of the broken bed to the oncoming shift, at 6:00 a.m. RN #1 said that she did not document the broken bed in the resident record nor did she contact the maintenance director, as she did not know what the maintenance director could do in the middle of the night. RN #1 said Resident #48 had asked to be moved to a different bed, but they did not have another bariatric bed to move her to. Resident #48 required a mechanical lift transfer and it would have taken more staff than were on shift to get the resident into the Hoyer lift and move her to a different bed. Two of the three CNAs on shift were not permitted to provide the resident care due to a prior complaint made by the resident and the resident's choice not to have certain staff provide her care. The wound nurse practitioner (WNP) was interviewed on 5/6/21 at 4:43 p.m. The WNP said he saw Resident #48 for the first time today (5/6/21) and assessed her skin and prescribed treatment. The WNP was scheduled to see the resident routinely until her wounds were healed. Per the WNP, the resident had four new moisture associated wounds on her buttocks, thigh and abdominal area compounded by fragile skin, obesity and friction from the Hoyer sling.

Based on record review and interviews, the facility failed to ensure treatment and care were provided in accordance with professional standards of practice, the comprehensive person centered care plan, and the residents choices for one (#1) out of five sample residents. The facility failed to ensure Resident #1 received a needed anticoagulant medication which was discontinued by a nurse practitioner without reason or notification. Due to the facility failures, it led to Resident #1 developing a [MEDICAL CONDITION] embolism which required hospitalization (see hospital records under record review). Findings include: I. Facility policy and procedure The Physician Services policy, dated April 2013, was provided by the nursing consultant (NC) on 3/9/21 at 12:30 p.m. It read, in pertinent part: The medical care of each resident is under the supervision of a licensed physician. The resident's attending physician participates in the resident's assessment and care planning, monitoring changes in the resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident. The attending physician will determine the relevance of any recommended interventions from any discipline. The physician is not obligated to accept these recommendations if he or she has clinically valid reasons for not doing so. The physician will perform pertinent, timely medical assessments; prescribe an appropriate medical regimen; provide adequate, timely information about the resident's condition and medical needs; visit the resident at appropriate intervals; and ensure adequate alternative coverage. Physician order [REDACTED]. II. Resident #1 A. Resident status Resident #1, under age 60, was admitted on [DATE]. According to the March 2021 computerized physician orders [REDACTED]. The 1/2/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She exhibited rejection of care. She required extensive or total assistance of two staff members with bed mobility, transfers, dressing, toileting and hygiene. She used a power chair for locomotion. B. Record review Review of the resident record revealed the resident received anticoagulation medications from her admission on 7/15/19 until 11/5/2020 for a history of [MEDICAL CONDITION] embolism (blockage of an artery in the lung) and [MEDICAL CONDITION] (blood clot develops in a vein ). The medication was discontinued by a nurse practitioner on 11/5/2020 and the discontinuation order read the medication was no longer indicated. The resident was seen by the nurse practitioner on 11/5/2020, though review of the provider note did not discuss the anticoagulant, the plan or reason for discontinuation, or any notification of the discontinuation to the resident or the resident's representative. Cross-reference F580 notification of changes. A nursing note dated 1/16/21 revealed the resident was being assisted with a brief change when she was rolled on her side, she stated she could not breathe and her eyes rolled back in her head. The certified nurse aide (CNA) called the nurse and called 911 and the resident regained consciousness. Her vital signs were blood pressure 184/102, heart rate 114, and oxygen saturation 84% and two liters per minute of oxygen was applied. The resident was assisted by the paramedics and taken to the hospital. Hospital records were reviewed from 1/16/21 through 1/20/21 revealed the resident had a saddle [MEDICAL CONDITIONS] with right heart strain and [MEDICAL CONDITION] (low oxygen) along with right leg occlusive [MEDICAL CONDITIONS] from the right femoral vein to popliteal vein. She had a thrombectomy (removing the blood clot) and was treated with a [MEDICATION NAME] (blood thinner) drip and would transition to Eliquis (oral blood thinner). The note revealed she would need lifelong anticoagulation. The hospital records revealed the resident had a prior history of [MEDICAL CONDITIONS] and [MEDICAL CONDITION] with an extensive [MEDICAL CONDITION] embolism (PE) in 2019 leading to a [MEDICAL CONDITION]. The hospital physician revealed after the thrombectomy, the resident's records from the nursing facility were reviewed extensively which showed the resident's Eliquis was discontinued on 11/5/2020. There was no record to indicate the reason for the discontinuation of the resident's anticoagulation. The resident was readmitted to the facility on [DATE] and has received Eliquis 5 milligrams (mg) by mouth two times a day since readmission. III. Resident interview Resident #1 was interviewed on 3/8/21 at 4:08 p.m. She stated she was sent to the hospital a month ago because she developed a blood clot. She stated she developed the blood clot because the facility discontinued her blood thinning medication she had been taking since her last blood clot in 2019. She stated no one told her or talked to her about discontinuing the medication and she stated she would have questioned the discontinuation and would not have agreed to it because of her history of blood clots. IV. Interviews A nurse practitioner (NP) #1 was interviewed on 3/8/21 at 3:00 p.m. He stated he did not work with Resident #1 and the provider who did was no longer working at the facility. He stated there could be many reasons to discontinue an anticoagulant medication, though the reason should be considered, documented and discussed prior to discontinuing a medication. The director of nursing (DON) was interviewed on 3/8/21 at 3:30 p.m. She stated the facility had taken actions related to Resident #1's anticoagulant medications to ensure the medication did not get discontinued again and that she received it on time. She stated medication changes were discussed in the daily clinical meeting to avoid any recurrence. NP #2 was interviewed on 3/8/21 at 4:24 p.m. She stated there were many possible reasons a medication could be discontinued. She stated tests should be done and the provider should weigh the risks versus the benefits of a medication prior to discontinuing. She stated the facility staff and the resident and or representative should be notified of a medication change. She stated the consideration and reasoning for discontinuation of a medication should be documented in a note. Registered nurse (RN) #1 was interviewed on 3/8/21 at 4:30 p.m. She stated if a resident medication was discontinued by a provider unexpectedly, she would talk to the provider to find out why the medication was discontinued. She stated she would worry about complications of discontinuing an anticoagulant medication. She stated she would ensure the resident and or representative knew about the medication change and answer any questions they might have. The regional director of clinical services (RDCS) was interviewed on 3/9/21 at 1:00 p.m. She stated the incident was reviewed by the facility related to Resident #1 developing a [MEDICAL CONDITION] embolism and being hospitalized . She stated the resident's orders were reviewed and the medication was discontinued without any documented reasoning or notification. She stated an action plan was put into place related to ensuring staff awareness related to medications. She stated the floor staff were trained related to anticoagulant medications and to ensure providers have reasons for discontinuing or changing medications as well as ensuring residents and representatives were notified of changes. She stated she completed a review of the residents who received anticoagulants and those who had had anticoagulants discontinued and no other issues were identified. She stated the management staff discussed medication changes in the daily clinical meeting, which was not happening consistently before the incident with Resident #1. -However, the action plan provided by the facility failed to include documentation of audits, education with staff and providers, or ongoing monitoring completed by the facility.

Based on observation, record review, and staff and resident interviews, the facility failed to provide adequate supervision to prevent smoking and non-smoking related accidents. Out of 26 sample residents, this facility failure affected five residents who smoked (#1, #2, #21, #22 and #25) and three residents (#15, #3, and #6) at risk for non-smoking related accidents. Specifically: SMOKING-RELATED ACCIDENTS Record review revealed on 7/26/2020, Resident #1 lit a cigarette in the smoking courtyard while his portable oxygen was running, supporting combustion and causing a fire and [MEDICAL CONDITION] the resident's face that required hospitalization . At the time, a housekeeping associate with no specific training was present to supervise the residents smoking in the courtyard. Following the 7/26/2020 incident, observations on 8/5, 8/6, and 8/11/2020 revealed continued failures of the facility to supervise residents as expected per facility policy, resident smoking assessment and/or care plan, or the facility's 8/3/2020 smoking list, in order to prevent smoking-related accidents. On 8/6/2020, observations revealed supervised smoker Resident #2 lighting a cigarette as she sat on a bench in the back of the smoking area out of staff's view; there were no staff or residents in the courtyard. Further, observations on 8/5/2020 revealed Resident #25, a supervised smoker, smoking independently and supervised smokers Residents #21 and #22 smoking without safety aprons they had been assessed to need. Then, on 8/11/2020, observations revealed Resident #2 smoking without a safety apron she was identified to need and Resident #21 in possession of cigarettes. Record review revealed inaccurate assessments of residents ' smoking abilities and insufficient training of staff on the hazards of smoking and smoking with oxygen. The facility's failures above created actual harm to Resident #1 and the likelihood of serious harm to Residents #2, #25, #22 and #21, all of whom required supervision to smoke safely. NON-SMOKING RELATED ACCIDENTS Further record review and observations revealed the facility failed to address other non-smoking accident hazards. Resident #3 failed to have the supervision - one on one sitter - he was care planned to receive due to his wandering and potential for elopement. Resident #15 failed to have a fall mat to prevent serious injury, Resident #6 failed to have a safety assessment for the use of a coffee machine in her room. Findings include: SMOKING ACCIDENTS I. Immediate jeopardy A. Findings of immediate jeopardy Record review revealed on 7/26/2020, Resident #1 lit a cigarette in the smoking courtyard while his portable oxygen was running, supporting combustion and causing a fire and [MEDICAL CONDITION] the resident's face that required hospitalization . At the time, a housekeeping associate with no specific training was present to supervise the residents smoking in the courtyard. Following the 7/26/2020 incident, observations on 8/5, 8/6, and 8/11/2020 revealed continued failures by the facility to supervise residents as expected per facility policy, assessment and/or care plan, or the facility's 8/3/2020 smoking list, to prevent smoking-related accidents. On 8/6/2020, observations revealed supervised smoker Resident #2 lighting a cigarette as she sat on a bench in the back of the smoking area out of staff's view; there were no staff or other residents in the courtyard. Observations on 8/5/2020 revealed supervised smoker Resident #25 smoking independently and supervised smokers Residents #21 and #22 smoking without the safety apron they had been assessed to need. Then, on 8/11/2020, observations revealed Resident #2 smoking without the safety apron she was identified to need and Resident #21 was found in possession of cigarettes. Record review and interviews revealed inaccurate assessments of residents ' smoking abilities and insufficient training of staff on the hazards of smoking and smoking with oxygen. The facility's failures created actual harm to Resident #1 and the likelihood of serious harm to Residents #2, #25, #22 and #21, all of whom required supervision to smoke safely, if the facility's failures were not corrected immediately. B. Imposition of immediate jeopardy On 8/11/2020 at 3:18 p.m., the nursing home administrator (NHA) was informed the facility's failures created an immediate jeopardy situation, contributing to actual harm for Resident #1 and the likelihood of serious harm for Resident #2, as well as other three other residents assessed as supervised smokers (#21, #22 and #25). C. Facility response to immediate jeopardy On 8/12/2020 at 5:25 p.m., the following abatement plan (draft #5) was submitted by the NHA to the Colorado Department of Public Health and Environment (CDPHE) to remove the immediate jeopardy situation. The abatement plan read: 1. All current smokers will be reassessed for safe smoking and their care plans updated as needed by the Director of Nursing (DON), Social Services Director (SSD) or designee by 08/11/2020. 2. Resident #1 was reassessed upon admission to the community and a new smoking assessment was complete on 8/5/20 to determine residents' smoking privileges. Additionally, a wander guard was placed on the portable oxygen tank of the resident to alarm the door if he attempted to enter the smoking patio with the oxygen tank still on. Care plan was reviewed to reflect his current status, and smoking capabilities. Performance improvement plan was completed immediately following the incident. Wander guard was placed on the top of the tank where the strap connects to the tank. 3. Resident #2 was immediately brought into the community upon learning that she was smoking. A physical assessment was completed for the resident to determine if there was an incident regarding her physical body. Resident was then re-assessed to determine her smoking capabilities inclusive of any adaptive equipment needs. A wander guard was added to the residents wheel to alert staff if and when she is attempting to enter the smoking area. 4. Resident(s) who are assessed to be independent with smoking will be allowed to smoke independently; however, for safety reasons supervised resident smoking materials will be kept at the nursing station in a locked case. 5. All residents who are utilizing portable oxygen will be educated on the importance of removing oxygen during the times they desire to smoke and will be considered supervised in the event that the portable tank is changed and the wander guard will be placed in the same location on the exchanged tank. However, residents who utilize o2 (oxygen) concentrators will remain independent if assessment determines they have independent smoking capabilities. Staff smoking supervisors will be educated on appropriate safety measures regarding oxygen and proper storage locations. Staff smoking supervisors will be educated on removing oxygen off residents prior to entering the smoking area. 6. Facility has created a supervised smoking checklist to assure accuracy of who is a supervised smoker while also highlighting any adaptive equipment that is to be utilized if needed and will update this list if there is a significant change or quarterly at minimum. SSD or DON will train all supervising staff on supervised smoking checklists prior to providing smoking supervision. All staff will be trained to the Smoking policy, smoking rules, supervised smokers, and adaptive equipment by 8/17/20. Facility will provide all adaptive equipment as needed to assure safe smoking practices for all residents. 7. The facility has created smoking rules that highlight appropriate smoking conduct to support a safe smoking environment which will be presented to residents who smoke upon admission. For residents who are current smokers, smoking rules were completed 8/11/20 be by SSD and DON. 8. The facility has revised the smoking policy to best support a safe smoking environment. 9. Oxygen door signs will be checked daily by the Plant Maintenance Director or designee to assure No oxygen signage is posted inside the smoking door and in the smoking area. On the weekend it will be the responsibility of the Charge nurse on duty. 10. A meeting will be held with smoking residents to discuss any changes or concerns with the facilities smoking policy and procedures quarterly and as needed. Meeting will be led by the SSD and DON. Meeting 1: 11/13/2020 Meeting 2: 2/12/2021 Meeting 3: 5/14/2021 Meeting 4: 8/13/2021 11. All staff will be educated on the facility safe smoking practices prior the start of their shift by the DON, or SSD starting 08/12/2020: a. Provision and posting of No-Smoking signs for residents who utilize oxygen and the designated smoking area b. The facility designated smoking areas c. Supervised Smoking Checklist d. Smoking rules e. Use of smoking blanket f. Supervision will be provided by facility staff who have been trained on all safety measures to prevent/minimize the risk of resident accidents or incidents during the smoking times and for those residents who require supervision. g. The provision and application of adaptive equipment for supervised residents while smoking 12. The plan will be presented to the QAPI Committee Meeting by 08/14/2020 D. Removal of the immediate jeopardy On 8/12/2020 at 5:25 p.m., the NHA was notified the immediate jeopardy had been removed based on staff interview and review of the facility's abatement plan. However, deficient practice remained at G level (actual harm) based on Resident #1's smoking injury 7/26/20 as well as systemic failures in the smoking procedures identified during survey 8/4/2020 - 8/13/2020. II. Smoking population and smoking policy A. Smoking population Review of the facility census list provided by the NHA on 8/6/2020, revealed 17 out of 59 facility residents smoked. Eleven of the 17 residents were determined to be independent smokers. This meant the residents kept and carried their own smoking materials and were allowed to go outside to smoke when they wanted to do so. Six residents were determined supervised smokers as of 8/3/2020, including Residents #1, #2, 21, #22, and #25. There were specific smoking times when the residents were to be supervised by staff when smoking. Two of the 17 residents used oxygen routinely, Resident #1 (supervised smoker) and Resident #26 (independent smoker). B. Facility Smoking Policy The policy read, in pertinent part, The facility will assess each smokers ' level of support and supervision by completing a smoking assessment. The facility may impose a smoking restriction on residents at any time if it is determined the resident cannot smoke safely with the available levels of support and supervision. Residents are encouraged to wear smoking aprons, and in addition, they will have the direct supervision of a staff member, worker at all times while smoking . Residents may not have or keep cigarettes, lighters fluids, including butane gas, or any other forms of gas or fluids at any time. III. Residents #1, #2, #25, #22, and #21 A. Failure to supervise Resident #1 to prevent a smoking-related accident 1. Resident status Resident #1, age 72, admitted to the facility on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. The CPO documented the resident had an order for [REDACTED].>The 5/21/2020 minimum data set (MDS) documented the resident required supervision with mobility both on and off the unit. The MDS documented the resident had a memory problem but was independent for decision making. The resident was unable to complete the brief interview for mental status (BIMS) evaluation for assessment of cognition. The 2/21/2020 MDS documented the resident had moderate cognitive impairment as evidenced by a BIMS score of ten out of 15. Record review revealed Resident #1 smoked cigarettes. 2. Incident 7/26/2020 Review of progress notes dated 7/26/2020 at 9:30 a.m. and incident audit report received on 8/10/2020 at 1:00 p.m. documented Resident #1 caught himself on fire while smoking with oxygen. Licensed practical nurse (LPN) #2 wrote the resident had soot all around his nasal area and partial burn to his mustache and lower lip, possible 1st to 2nd degree burn possibly experienced a second-degree burn on his lips and face. When asked what happened, the resident replied, I forgot to ask the staff to take off my oxygen container. When asked where he got his cigarette, he said he had his own cigarettes and motioned with his head pointing at his cigarette tucked in between the cushion on the right side of his wheelchair. A call to Resident #1's wife revealed her caregiver brought Resident #1 groceries on 7/22/2020 and brought him cigarettes as well. The resident received Tylenol and a cold compress for his face. He was transferred to the hospital per physician orders. Housekeeping associate #1 (HSK#1) was interviewed on 8/5/2020 at 10:00 a.m. She said she was supervising the residents in the smoking courtyard on 7/26/2020. She said she was outside in the smoking area that day at approximately 9:30 a.m. near Resident #1. She turned around from the flowerbed and noticed the resident's lip and beard were on fire. She said she removed the hose from the resident's nose and tossed the oxygen. Resident # 21 was interviewed on 8/5/2020 at 11 a.m. She said she was outside smoking with about five other smokers on 7/26/2020. She said she heard a loud pop. She then saw Resident #1 on fire. She said she did not notice where the resident had gotten his cigarettes. Resident #27 was interviewed on 8/9/2020 at approximately 10:00 p.m. The resident said he was present during the incident with Resident #1 on 7/26/2020. He said he was sitting on the bench and the housekeeping associate #1 was standing near him. He said Resident #1 was smoking with oxygen on and he saw the flames under his nose. He said the housekeeping associate ran over and put the fire out with her hands. Resident # 20 was interviewed on 8/10/2020 at 3:40 p.m. He said he was out in the smoking area on the day Resident #1 caught himself on fire. He said he did not notice the oxygen on the resident's face. He said he saw the resident light a cigarette and saw his face catch on fire. He said the staff member who was out in the area immediately took the oxygen from the resident and put out the fire on his face. He said he went into the facility to get a nurse for the resident. He said he saw the paramedics come a few minutes later and take the resident from the facility. 3. Facility failure to protect Resident #1 from an accident while smoking a. Failure to ensure Resident #1's smoking abilities were accurately assessed to meet his need for supervision. Record review revealed conflicting information on Resident #1's smoking abilities. Specifically, smoking assessments dated 2/18, 2/19, 5/19, 5/20, 6/2 and 6/24/2020, documented Resident #1 was an independent smoker, which indicated he had his own smoking materials. However, his care plan during much of this same period, dated 3/25/2020 and revised 7/15/2020, documented he was to be supervised when smoking at all times. There was no evidence in Resident #1's record to explain this discrepancy; the resident's care plan provided no explanation why the resident was a supervised smoker and what interventions this triggered. In an interview on 8/13/2020 at 12:33 p.m., the NHA said he was not aware that the resident's care plan did not match his smoking assessments. Moreover, his most recent smoking assessment prior to the 7/26/2020 incident, dated 6/24/2020, documented he had no cognitive loss. This was inaccurate as his 5/21/2020 MDS documented the resident was unable to complete a BIMS due to cognitive impairment. Indeed, review of a facility quality improvement (QAPI) root cause analysis of the 7/26/2020 incident provided by the NHA on 8/17/2020 revealed the QAPI found Resident #1's smoking assessments were inconsistent. Meeting notes read: Resident #1 had a BIMS of 5 and a [DIAGNOSES REDACTED]. His being deemed an independent smoker may not have been appropriate. b. Failure to ensure the facility's Smoking Policy was followed. (1) Although the facility policy read, Residents may not have or keep cigarettes, lighters fluids at any time, review of Resident #1's most recent smoking assessment dated [DATE] documented resident had control of his own smoking materials. Resident #1's statement after the 7/26/2020 incident, that he had his own cigarettes, pointing to one on the cushion in his wheelchair, revealed this was the case on 7/26/2020, even though his care plan read he was a supervised smoker. There was no evidence the supervising staff was aware the resident had his own cigarettes or questioned where the resident had obtained his cigarettes until after the incident. (2) Although facility policy read, No oxygen is allowed in designated smoking areas at any time, interview with the NHA revealed no signage was in place to direct residents, visitors, and staff that oxygen is flammable and must be removed before entering the smoking area until after the incident on 7/26/2020. Further, there was no evidence the supervising staff observed and attempted to turn off and remove Resident #1's portable oxygen when he entered the smoking courtyard. c. Failure to ensure staff members supervising residents who required supervision when smoking were trained in how to perform their duties. The NHA was interviewed on 8/13/2020 at 12:33 p.m. The NHA said his employment started at the facility in November 2019. He said he was not sure if any training had been completed with the staff on the smoking policy during his administration, prior to the incident from 7/26/2020. He said he himself had not completed any training on smoking with the staff. He said housekeeping associate #1 who was supervising the residents during the incident on 7/26/2020 did not have training on the smoking policy. He further stated the new maintenance man had not been trained on the smoking policy or smoking areas. 4. Actions taken after 7/27/2020 incident a. Individual-focused actions According to the 7/26/2020 QAPI meeting notes provided by the facility on 8/17/2020, corrective action for Resident #1 included the resident was to be a supervised smoker and his smoking materials stored by the facility to which he would have access during supervised smoking times. A wander guard would be placed on the resident's portable oxygen tank to alert the staff if the resident was trying to go out to the smoking area with his oxygen on. Resident #1's smoking assessment dated [DATE] read he was a supervised smoker. Physician orders, revised on 8/6/2020 read the resident was to be offered three smoke breaks per day. The orders included the resident was to be outside at opposite times of other smokers. Another order beginning 8/6/2020 read to place an alarm on the resident's portable oxygen tank to alert staff if the resident tried to go outside by himself. b. Systemic actions According to the 7/26/2020 QAPI meeting notes, systemic action included an audit of all residents that smoked to ensure the residents have an accurate smoking assessment within the last quarter, an accurate/appropriate smoking care plan, wear supplemental oxygen, and to determine if a resident is independent or supervised with smoking. Smoking materials for cognitive impairments/supervised smokers will be kept secure by the facility staff and will not be allowed to be stored in the resident's possession. The facility issued a Supervised Smoking Policy dated 7/26/2020 that directed to staff supervising smokers in the smoking area to: -look at all residents to ensure they are safe -ensure oxygen has been removed for all residents and, if not, immediately remove it, and -make sure that smoking residents who are required to wear an apron, or other devices, are wearing items during smoking. -not leave supervised smokers in the smoking area A Smoker's Meeting was held 7/30/2020 to discuss adjustments to smoking at the facility. The NHA, in his interview on 8/13/2020 at 12:34 p.m., said staff called him the day of the incident involving Resident #1. He said he immediately did a complete assessment on all of the residents, focusing on the supervised smokers and taking all of the smoking materials away from them. He said he was not involved with the smoking policy prior to this incident, stating the social service director (SSD) was to review the smoking policy every six months. B. Resident #2, #25, #21, and #22 - Continued failure to supervise residents to prevent smoking-related accidents and failure to consistently implement post 7/26/2020 systemic actions set forth above. Following the 7/26/2020 incident, observations on 8/5, 8/6, and 8/11/2020 revealed continued failure of the facility to supervise residents as expected per facility policy, assessment and/or care plan or the facility's 8/3/2020 smoking list, in order to prevent smoking-related accidents. Specifically, observations revealed supervised smokers smoking without supervision, without safety aprons, and in possession of their own smoking materials. 1. Resident #2 Resident #2, age 69, admitted to the facility on [DATE]. According to the August 2020 CPO, her [DIAGNOSES REDACTED]. She required supervision and set up help for locomotion on the unit. She required a wheelchair for locomotion. Record review revealed Resident #2's smoking assessment, dated 7/26/2020, read the resident did not require a safety apron while smoking and a progress note from 7/27/2020 revealed the resident was offered a safety apron and refused. However, the 8/3/2020 smoking list identified the resident was to wear a safety apron when smoking. In addition, her care plan, updated 7/29/2020, read the resident's cigarettes and lighter were to be kept in a secure location. On 8/5/2020 at 3:06 p.m. and again on 8/6/2020 at 11:03 a.m., observations revealed Resident #2 smoking outside with staff present. She was not wearing a safety apron either time. On 8/6/2020 at 5:34 p.m., observations revealed Resident #2, without a safety apron, sitting on the bench in the back of the smoking courtyard out of staff view. It was dinnertime and no staff or other residents were in the courtyard. The resident had a cigarette in her mouth. She reached into her pocket and pulled out a lighter. She lit her cigarette and started smoking. On 8/11/2020 at 1:45 p.m., the assistant director of nursing (ADON) provided an incident report regarding this incident. The report revealed Resident #2 was found smoking alone in the courtyard without an apron. The resident was a supervised smoker. The action taken by the facility included removal of cigarettes and lighters and a skin assessment for injuries. The resident could not tell staff where she got her cigarette and lighter. With the consent of the resident's family, staff searched the resident's room for cigarettes. The investigation did not reveal how the resident obtained the cigarette or lighter. On 8/11/2020 at 3:01 p.m., observations revealed Resident #2 smoking outside in the courtyard. Staff was present, but the resident was not wearing a safety apron. The director of nursing (DON), interviewed on 8/6/2020 at 6:30 p.m., said Resident #2 was only allowed to smoke during designated smoking times because she was a supervised smoker. She said they had gone over the smoking policy with the resident and attempted a smoking contract, which the resident refused to sign. 2. Resident #25 Record review revealed Resident #25's 5/21/20 smoking assessment documented he was independent with smoking; however, the facility smoking list dated 8/3/2020, listed him as a supervised smoker. On 8/5/2020 at 2:15 p.m., observations revealed Resident #25 received a cigarette from registered nurse (RN) #1 at the nurses ' station. He then left and went out to the smoking courtyard by himself to smoke. No staff was present to supervise him. On 8/6/2020 at 4:46 p.m., observations again revealed Resident #25 smoking a cigarette in the courtyard with no staff present to supervise him. 3. Resident #21 Record review revealed Resident #21 was assessed on 7/26/2020 as a supervised smoker. Per the assessment, her care plan and the 8/3/2020 smoking list, she was to wear a safety apron. Further, per her assessment and care plan, her cigarettes were to be kept by the staff. On 8/5/2020 at approximately 3:15 p.m., observations revealed Resident #21 smoking outside in the smoking courtyard during one of the designated smoking times. She did not have an apron on. On 8/11/2020 approximately 4:00 p.m., the resident was observed in her room. She had a zipper pouch around her waist. Inside the open zipper pouch was a pack of cigarettes. 4. Resident #22 Record review revealed Resident #22 was assessed on 7/26/2020 as a supervised smoker and was to wear an apron while smoking. On 8/5/2020 at approximately 3:15 p.m., observations revealed the resident was outside smoking. He did not have a safety apron on while he smoked. 4. Staff interviews on supervised smoking Interviews revealed conflicting understanding of the procedures for supervised smoking and the observations above revealed the procedures articulated were not consistently followed. Certified nurse aide (CNA) #2 was interviewed on 8/11/2020 at 11:50 a.m. She said she has had to supervise the smokers before. She said she gathers all the residents in the common area, puts the aprons on, and reminds them if they don't wear one, they cannot smoke. She said she then gathers their cigarettes and a lighter from the box in the nurses ' station and takes the residents outside. She said each resident can have two cigarettes and can enter the building when they are done smoking. She said she cannot enter the building until all the supervised smokers have finished smoking. She said if a resident missed the designated smoking time, he or she has to wait until the next time to smoke. She said she received training about smoking safety and a demonstration on how to use the fire extinguisher. She said portable oxygen canisters had to be left at the nurse's station before a resident could go outside to smoke. RN #3 was interviewed on 8/11/2020 at 4:01 p.m. She said all the cigarettes and lighters for supervised smokers were kept in the locked nurses ' station and given to staff at supervised smoking times. She said the supervising staff was to light the cigarettes for the supervised residents and hold onto their second cigarette until they were done with their first one. Licensed vocational nurse (LVN) #2 was interviewed on 8/12/2020 at 2:50 p.m. She said the safety aprons for smokers were kept in the nurses ' station. She said the residents had a right to refuse the apron and still go outside to smoke. She said the lighter was given to the supervising staff member to light the cigarettes for the residents. NON-SMOKING RELATED ACCIDENTS Record review, observations and interviews revealed the facility failed to address other non-smoking-related accident hazards. A. Failure to prevent Resident #3 from wandering outside the facility 1. Resident status Resident #3, aged 60, admitted to the facility on [DATE]. According to the August 2020 CPOs, the resident's [DIAGNOSES REDACTED]. The 7/30/2020 MDS documented Resident #3 required supervision for mobility. The resident was documented to wander 1 to 3 days and his wandering put him at significant risk of getting to a potentially dangerous place such as outside the facility. 2. Failure to implement supervision for wandering a. Record review The 4/23/2020 care plan documented the approaches for managing Resident #3's wandering included one-on-one for safety and care needs related to wandering. b. Observations 8/4/2020 and staff interviews 8/4 and 8/6/2020 On 8/4/2020 at 9:15 p.m., observations revealed the resident wandering the hallway. He did not have a one-on-one sitter with him. RN #1, who was in charge of the resident's care, was interviewed at 9:30 p.m. She said Resident #3 did not have a sitter. She said staff keep their eye on the resident when he is out of his room and wandering the hallways. She also said he had a wander guard bracelet. On 8/6/2020 at approximately 2:00 p.m., the NHA and the director of operations (DOO) were interviewed. The NHA acknowledged a sitter for Resident #3 was not scheduled on the evening of 8/4/2020. The NHA said the facility's goal was to have four CNAs, a sitter, and two licensed nurses on the evening shift. The DOO and the NHA gave assurances a sitter would be in place for Resident #3 from now on. The director of operations said Resident #3 was going to remain in the facility indefinitely; the facility was no longer looking for alternative placement for him. c. Observations and interview 8/9/2020 After the meeting on 8/6/2020 (see above) with the NHA and DOO and their assurance that the plan of correction would be met with a sitter for Resident #3, observations revealed the resident continued to be without a sitter. On 8/9/2020 at 9:15 p.m., Resident #3 was in his room; he did not have a sitter with him in his room. At the time, RN #1 was across the hall assisting another resident to bed. On 8/9/2020 at approximately 9:30 p.m., RN #1 was interviewed. She said the resident had a sitter up until 8:30 p.m. She said had been sitting with him; however, the resident across the hall had asked to go to bed, so she was helping her. On 8/9/2020 at approximately 9:30 p.m., RN #2 was interviewed. RN #2 said he worked on 8/8/2020 on the 6:00 p.m. to 6:00 a.m. shift. He said no sitter had been scheduled for Resident #3 on 8/8/2020. He said he had removed himself from the working the floor to sit with the resident, although he said he was not always with the resident. He said the floor he was assigned to work was an easier assignment and the CNA on his floor kept an eye on his residents. B. Failure to place a fall mat to prevent injury to Resident #15 1. Resident status Resident #15, age 97, admitted to the facility on [DATE]. According to the August 2020 CPO, her [DIAGNOSES REDACTED]. The 5/28/2020 MDS assessment revealed the resident had cognitive impairment with a brief interview for mental status score of 6 out of 15. She required extensive two-person assistance with transfers and bed mobility. She required a wheelchair for locomotion. The resident's care plan, updated on 5/22/2020, documented the use of a fall mat and the bed to be in the lowest position when the resident was in bed. A fall investigation from 7/30/2020 was received from the DON on 8/13/2020 at 10:00 a.m. It documented the resident slid out of her chair in the hallway. The nurse assessed the resident and three staff assisted the resident back into her chair. An interdisciplinary team (IDT) note dated 8/4/2020 discussed the resident's fall from 7/30/2020. Fall risks included weakness, dementia, and confusion. Interventions included a fall mat and physical therapy screen. 2. Observations On 8/5/2020 at 3:00 p.m., observations revealed Resident #15 sleeping in bed. A fall mat was not on the floor at the bedside. On 8/6/2020 at 11:00 a.m., observati(TRUNCATED)

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically: The record review and interviews with staff showed the facility failed to provide adequate supervision to prevent smoking accidents. The investigation revealed an ineffective system in implementing a facility policy on smoking. These failures contributed to an immediate jeopardy situation and a resident experiencing harm level of injury related to smoking with oxygen which resulted in [MEDICAL CONDITION] his face. Cross-reference F689: The facility failed to ensure resident safety with accident hazards. The facility's failure to identify and address smoking related accidents resulted in the facility having an immediate jeopardy. The facility's failure to protect residents from accident hazards was cited at a K level. Cross-reference F725: The facility failed to have adequate nurse staffing. The facility was cited at cited at a F level widespread for more than minimal harm. Additional failures included, lack of leadership to address sufficient nurse staffing, which as resulted in inadequate staffing, the facility had delayed call light response, failed to provide assistance with activities of daily living (ADLs), lack of pressure ulcer interventions to prevent pressure ulcers, and an adequate infection control program. Findings include: I. Current findings in area of quality of care-Failure to ensure facility policy was implemented to identify, prevent, six supervised smoking residents (Residents #1, #2, 21, #22, #24, and #25). A. Facility policy The facility read in pertinent parts, will assess each stated smokers ' level of support and supervision by completing a smoking assessment. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. Residents are encouraged to wear smoking aprons, and in addition, they will have the indirect supervision of a staff member, worker at all times while smoking Residents may not have or keep cigarettes, lighters fluids including butane gas, or any other forms of gas or fluids at any time. B. Cross-reference F689K. Facility administration failed to have a system/plan to ensure residents who used oxygen and who had access to the designated smoking areas were monitored, assessed and to implement smoking interventions, and to ensure the smoking policy was followed. These failures created situations that resulted in an immediate jeopardy situation. -Observation, record review, and interviews with staff, and residents demonstrated the facility did not have an effective system in place to implement preventive safety measures for residents who were to be supervised with smoking. -Smoking assessments were not completed accurately to ensure the most effective interventions were in place. The care plans did not match the assessments and interventions. -Smoking paraphernalia was not stored with staff and safely secured. -Staff were not adequately trained to ensure they knew the importance of smoking safety which included, but not limited to the use of oxygen. C. Interviews The NHA was interviewed on 8/13/2020 at 12:33 p.m. The NHA said he was called the morning of 7/26/2020 in regards to Resident #1 smoking with oxygen and as a result received [MEDICAL CONDITION] the oxygen exploding with the lit cigarette. The NHA said smoking assessments were completed on all of the residents who smoked. He said he was not involved with any of the assessments, and he was not aware some of the previous assessments were not accurately completed and that the care plans were not accurate or followed in regards to the smoking interventions. The NHA said his employment started at the facility November 2019. He said the facility did have a smoking policy, however, he was not sure if any training had been completed with the staff during his administration prior to the incident from 7/26/2020. He said he himself had not completed any training on smoking with the staff. He said the director of housekeeping who was out supervising the residents during the incident on 7/26/2020 did not have training on the smoking. II. Current findings in area of quality of care Facility administration failed to consistently provide adequate nursing staff which considered the acuity and [DIAGNOSES REDACTED]. A. Cross-referenced citations As a result of inadequate staffing, the facility had delayed call light response, failed to provide assistance with activities of daily living (ADLs), lack of pressure ulcer interventions to prevent pressure ulcers, and an adequate infection control program. Cross-reference F-677, Maintain activities of daily living for dependent residents; Cross-reference F-686, Treatment, prevent pressure ulcers;and, Cross-reference F-880, Infection control program. B. Staff turnover inadequacies The facility had experienced a significant staff turnover with the department heads. The turnover was as follows for staff member and start dates: Director of nurses (DON) 6/24/2020; Assistant director of nurses (ADON) 6/30/2020; Medical records director 7/8/2020; Social service director 6/15/2020; Activity director #1 8/6/2020; Activity director #2 7/23/2020; Dietary manager 7/12/2020; Maintenance director 8/5/2020; and, Housekeeping supervisor August 2020. C. Interviews The DON and the ADON was interviewed on 8/13/2020 at approximately 11:00 a.m. The DON said she had started to work at the facility approximately five weeks ago. She said that since working at the facility the staffing has been a challenge. She said that the facility did not staff according to accuity, however, she was activity working on a plan to staff to accuity. The DON was aware that the facility worked without the appropriate amount of staff at times. The NHA was interviewed on 8/13/2020 at 12:33 p.m. The NHA said he was aware of the turnover in both his department heads, and the front line nurse staffing. He said a performance improvement plan had been written and he was using multiple agencies to help cover open shifts. He said they were also holding raffles, and starting a bonus program. He said if he received a complaint from a resident, he told them they were doing everything they could. He said he was not notified when the staffing was not adequate. The NHA said stability of staff was tough day to day during the pandemic. He said that the facility was going to start focusing on the onboarding process of the staff and complete exit interviews. III. Previous survey dated 6/5/2020 A. Previous F835 The facility was cited F835 on 6/5/2020 for the administration failing to have an effective system in implementing facility policy on the following areas nutrition, hydration and in maintaining acceptable nutritional parameters to ensure adequate nutrition, scope of H. The plan of correction indicated a consulting nursing home administrator (CNHA) was to be used to provide consultation and oversight. B. Interview The NHA was interviewed on 8/13/2020 at 12:33 p.m. The NHA said the CNHA was used to bounce ideas off of, and had one-on-one with the CNHA one time a week. He said he was positive that the direction he was receiving was heading in the right direction.

Based on resident observation, record review and interviews, the facility failed to ensure one Resident (#8) of three residents reviewed for pressure ulcers, received the treatment and services to prevent pressure ulcer development. The facility failed to prevent the development of three stage 2 pressure ulcers to Resident #8 ' s buttocks. The facility ' s failures contributed to the development of three stage II pressure ulcers to Resident #8's buttocks that were not consistently assessed and treated. The facility failed to provide incontinent care in a timely manner; accurately and consistently document Resident #8's wound on her bottom; ensure Resident #8's wound care was provided consistently and according to physician orders; and update the resident's care plan with newly identified skin integrity issues and interventions. Cross-reference F657 care plan timing and revision, F677 incontinence care and F725 sufficient staffing. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel (NPIAP) Prevention and treatment of [REDACTED].cvph.org/data/files/NPIAP% 9.pdf (third edition published 2019, retrieved on 8/4/2020), it read in part, Excess moisture on the skin surface (e.g. due to increased perspiration or incontinence) also increases skin vulnerability to damage related to skin maceration, pressure, and shear forces. Maintaining skin integrity is essential in the prevention of pressure injuries. Implement a skin care regimen that includes keeping the skin clean and appropriately hydrated, and cleansing the skin promptly after episodes of incontinence. Repositioning and mobilizing individuals is an important component in the prevention of pressure injuries. Extended periods of lying or sitting on a particular part of the body and failure to redistribute the pressure on the body surface can result in sustained deformation of soft tissues, and ultimately, in tissue damage. II. Facility policies The Pressure Ulcer/Skin Breakdown clinical protocol, revised April 2018, was provided by the director of nurses (DON) on 8/13/2020 at 9:00 a.m. It read in pertinent part; The nursing staff and practitioners will assess and document an individual's significant risk factor for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcers. In addition, the nurse shall describe and document/report the following: -Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue; -Pain assessment; -Residents mobility status; -Current treatments, including support surfaces; and -All active diagnoses. The physician will assist the staff to identify the type and characteristics of an ulcer. The Perineal Care/Incontinence Care, policy revised February 2018 was provided by the DON on 8/9/2020 at 9:01 p.m. It read in pertinent part; To provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident ' s skin condition. Perineal care is to be offered every 2 hours and before and after meals if needed. III. Resident status Resident #8, age 63, was admitted on [DATE]. According to the August 2020 computerized physician orders [REDACTED]. -The [DIAGNOSES REDACTED]. The 7/15/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She required extensive assistance of two persons with bed mobility, transfers and dressing and extensive assistance with one person assistance for toilet use and personal hygiene. Skin said was marked no to unhealed pressure ulcers and marked yes to moisture associated skin damage (MASA). IV. Continuous observations failure to provide incontinent care timely Resident #8 was observed on 8/4/2020 at 9:45 p.m. to have her call light on. Certified nurse aide (CNA) #8 answered the call light, and the resident said she had to have her brief changed as she had diarrhea. CNA did not assist the resident at that time and said she would be right back. -At 9:47 p.m. Resident #17 entered Resident #8 room. CNA #8 assisted Resident #17 out of the room and back to his room. She shut the door to Resident #8 ' s room. Resident #8 reminded CNA #8 she needed a brief change and again the CNA said she would be right back. -At 10:05 p.m. licensed practical nurse (LPN) #1 went into the room to check the residents blood pressure and then left the room. -At 10:14 p.m. the resident put her call light on. LPN #1 answered the light and the resident asked why the CNA did not not come back. LPN told the resident she would find the CNA and she would be right back. The resident said to the nurse she had diarrhea and wanted medication for that. LPN left the room and shut the residents door. -At 10:25 p.m. LPN #1 went into the residents room to tell her she had to call the physician to get an order for [REDACTED]. Almost an hour later at 10:33 p.m. CNA #5 assisted the resident to change her brief. CNA donned gloves and cleaned the front of the peri area under the brief. The skin was bright red around the peri area and a foley (tube into the bladder) catheter was present. There was a strong odor of urine and feces. The resident rolled to her left side and CNA #5 took off the brief. There were large amounts of feces on her bottom. CNA #5 cleaned the area with peri wipes and the resident grimaced and moaned with discomfort. The residents bottom was bright red and excoriated in a large area around her buttocks and inner thighs up to her sacral area. She had three open wounds on her left buttocks cheek. Two open wounds were about the size of a dime and another one a little smaller. CNA #5 changed gloves but did not wash his hands in between. He applied barrier cream that was in the resident bedside drawer to the residents bottom, buttock check area and thighs. The cream was applied to the three open wounds. CNA put a clean brief on the resident, cleaned up the area and washed his hands. V. Record review Potential for skin impairment care plan revised on 3/7/2020 revealed impairment of skin due to poor mobility and a history of pressure ulcers. The resident will have no skin breakdown through the next review target date of 8/3/2020. The resident will be encouraged to have frequent repositioning and offloading and will have a weekly skin assessment. The care plan was not updated to include the stage two pressure wounds to the buttocks, treatment or interventions to prevent the development or worsening of the wound. (see below) Treatment administration record (TAR) for July 2020 revealed an order dated 6/13/2020 to cleanse the wound with wound cleanser, apply powdered collagen medication and hydrogel medication to the wound bed. Apply a dry dressing one time a day for wound care. The order did not say where the wound was located and the order was discontinued on 7/9/2020. -On 7/10/2020 a new order read; wash coccyx with wound cleanser, apply skin prep to the wound daily and continue to apply barrier cream with incontinent episodes one time a day for skin breakdown prevention. Another order read wash left glut with wound cleanser, apply skin prep to the wound daily for gluteal trauma related to incontinence. Both orders were discontinued on 7/23/2020. -On 7/17/2020 a new order read; cleanse left buttock with wound cleanser, apply [MEDICATION NAME] medication to the wound bed, and cover with a foam dressing. Change daily and as needed every shift for MASD. -On 7/24/2020 a new order read; wash coccyx with wound cleanser, apply skin prep to peri-wound and barrier cream every shift and as needed for skin protection. There was an admission skin assessment completed on 7/16/2020 that revealed a new skin breakdown to the left buttocks which measured 1.5 centimeters (cm) x 1.8 cm. -Full skin assessment completed on 7/30/2020 showed the left buttocks measurement to be 2 cm x 1.2 cm. According to the August 2020 CPO, the resident had the following orders: -Cleanse left buttock and left gluteal fold with wound cleanser, apply [MEDICATION NAME] to wound bed, cover with [MEDICATION NAME] dressing, revised order date 8/9/2020. -Change daily and as needed every day shift for MASD, ordered 8/9/2020. -Please offer to reposition every two hours as resident will allow. Chart compliance and refusals every two hours, revised order date 8/9/2020. Weekly summary dated 8/2/2020 for the skin section had a check box marked no for any open skin issues and a narrative note in a box that read, Resident #8 had a condition on the peri area that extends to bilateral buttock with small open area on the left side buttocks. Another summary dated 8/9/2020 asked if there were any current pressure injuries and the box was marked no with a narrative note in the box that read, buttock/coccyx open area with treatment ongoing as ordered and left buttock open area with treatment ongoing as ordered. The skin assessment-non pressure ulcer form dated 8/5/2020 read in pertinent part; Cleanse with normal saline, apply Medi-honey to wound bed, apply skin prep to peri-wound cover with dry dressing. Change daily. A question box asking has the medical doctor (MD) classified the wound as unavoidable and that box was marked yes. If the box was marked yes, provide the date of the note specifying wound as unavoidable, and the date was 7/30/2020. -On 8/7/2020 skin assessment the box with the MD classified the wound unavoidable was marked no. Nurse practitioner note dated 7/16/2020 read there was a history of an unspecified open wound of buttock. No other information was given about the wound. VI. Interviews Licensed vocational nurse (LVN) #3 was interviewed on 8/13/2020 at 9:39 a.m. She said skin assessments were completed weekly by the floor nurse and the director of nurses (DON) did wound rounds with the doctor on Thursdays. LVN #1 was interviewed on 8/13/2020 at 10:12 a.m. She said when a resident developed a new skin issue an assessment was completed. She said the DON was notified and new orders for wound care were entered. She said the DON and the wound doctor staged the wounds once they looked at them. The DON was interviewed on 8/6/2020 at 5:30 p.m. She said Resident #8 had a moisture associated skin damage (MASD) and not a pressure ulcer. She said the MASD was on her bottom area and not a pressure area. VII. Follow-up The DON was interviewed again on 8/10/2020 at 11:56 a.m. The DON clarified Resident #8 had a pressure ulcer stage two on her bottom area not a MASD. The DON was interviewed for a third time on 8/13/2020 at 4:13 p.m. she said the nurses notified her of any new skin issues and the residents names were put on the list for the wound doctor to assess them. She said the facility just hired a new wound doctor. She said a weekly skin assessment was completed and the nurses document any changes. The care plan was updated to reflect the new wound.

Based on observations, record review and interviews, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual or desirable body weight range, resulting in significant/severe weight loss, affecting six (#1, #2, #3, #4, #5, #6) of six residents reviewed for nutritional status out of 11 total sample residents. Specifically: Upon identification of weight loss, the facility failed to identify, implement, monitor, and modify interventions consistent with the resident's assessed conditions, needs, choices, preferences and goals, in order to promote their nutritional status. These failures contributed to Resident #1 experiencing an 18 percent (%) (severe) weight loss, Resident #5 experiencing a 21% (severe) weight loss, Resident #2 experiencing a 9.71% (severe) in three months, Resident #3 experiencing an 11.85% (severe) weight loss in three months, Resident #4 experiencing a 9.57% weight loss in three months and Resident #6 experiencing a 6.61% (severe) weight loss in one month. Cross reference F803 (Menus), F806 (Preferences and Substitutes), F809 (Frequency of meals and snacks) and F841 (Medical Director) Findings include: I. Facility policy and procedure A. The Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol revised [DATE], was provided by the nursing home administrator (NHA) on [DATE] at 9:35 a.m. It revealed in pertinent part: The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. The staff and physician will define the individual's current nutritional status and identify individuals with anorexia, recent weight loss, and significant risk for impaired nutrition. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a) 1 month - 5% weight loss is significant; greater than 5% is severe, b) 3 months - 7.5% weight loss is significant; greater than 7.5% is severe, c) 6 month - 10% weight loss is significant; greater than 10% is severe. The physician, with the help of the multidisciplinary team (IDT), will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition. The physician will review possible causes of weight loss with the nursing staff and/or dietician before ordering interventions. The physician (or staff, based on a discussion with the physician) will document relevant medical observations and, regarding the nature, severity, causes, and consequences of impaired nutritional status, especially in complex situations or where multiple, active causes may co-exist. The staff and physician will identify any pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes. Treatment decisions should consider all pertinent confirmation or evidence, such as food intake and overall condition. Nutritional needs: The dietician will help the physician determine the appropriate diet for the resident based on the resident's degree of nutritional impairment. Environmental factors: Staff will ensure that the food served to the resident has an appealing aroma, flavor, form, temperature, and appearance. Supplementation: Strategies to increase a resident's intake of nutrients and calories may include fortification of food, providing between-meal snacks and/or nutritional supplementation. The physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals; Evaluating the resident's response should be based on defined criteria for improvement/worsening of nutritional status; Observing for and documenting any sustained decline in appetite and/or food intake; and Observing for and reporting significant weight gain and/or loss. B. The Weight Pathway Policy was provided by the NHA on [DATE] at 9:35 a.m. It read, in pertinent part: In the event the weight of the resident varies +/- three lbs from the prior weight, the restorative aide must solicit the treatment and lead to witness a reweight. In the event the weight remains the same it will be documented, with two separate entries, and reweighed the following day. In the event the weight still varies the following day, a progress note will be made, the doctor and registered dietician (RD) made aware of change, and change of condition process started for nurses where they document every shift on the encouragement of fluids if applicable, intake of residents, or any change in eating patterns. The interdisciplinary team (IDT) will meet to review weights. The weight summary report should be pulled with a six month lookback for review. These will be the weights to review, no other report to be utilized. It is the expectation that the director of nursing (DON) would attend the monthly weight meeting. Weekly weights determined in the meeting were based on criteria of residents with greater than 3 lbs from the last weight, 5% in 30 days, 7% in 90 days or 10 % in 180 days. All interventions are to be care planned in the moment at IDT for any resident that is added for review every week. Nutrition at Risk (NAR) meetings should include minimally the Director of Nursing, and the dietary manager, weekly. The Dietician, Social Services, activities and administrator should be included monthly in the initial meeting for the month. Ensure actual intakes are reviewed prior to the NAR meeting and every day. Use the alert on your dashboard as a way to guide the staff to be proactive. That information is something the dietary manager should assess. Minimum intake for fluids, food, and protein will be based on your Dietician's assessment so please ensure documentation is occurring. When performing a NAR review and determining interventions ensure you recap what was previously tried, review the care plan and ensure implementation is plausible. 1. Interviews The DON was interviewed on [DATE] at 3:05 p.m. The DON said if the weight was off, and the resident had a weight loss of plus or minus three pounds, then the resident should be reweighed within 48 hours. She said the scale had been calibrated within the past 60 days. The DON was interviewed a second time on [DATE] at approximately 4:00 p.m. She said the scale was calibrated on [DATE]. II. Facility failure to take steps to promote residents' nutritional status upon identification of weight loss. A. Resident #1 1. Resident status Resident #1, age 80, was admitted to the facility on [DATE]. According to the computerized physician orders [REDACTED]. The MDS dated [DATE] indicated the resident experienced a weight loss of 5% or more in the last month or a loss of 10% or more in last 6 months. The MDS revealed the resident weighed 126 lbs. The weights and vitals scale located in the residents chart offered the resident weighed 124.4 lbs on [DATE] and 117.2 lbs on [DATE]. A minimum data set assessment ((MDS) dated [DATE], coded the resident as having short-term memory impairments and modified independence with decision-making. She was coded as requiring oversight and encouragement with eating. The resident was 67 inches tall and weighed 126; her usual body weight was 140. The MDS documented the resident was not on a weight loss program. The resident's care plan, dated [DATE], read the resident was at nutritional risk and had unintended weight loss. The resident fed herself with cueing and reminders from the staff. Staff should offer snacks and fluids in between meals on a daily basis. 2. Record review revealed Resident #1 had a severe weight loss from [DATE] to [DATE]. Weight chart for Resident #1 revealed Resident #1 had an 18% weight loss from [DATE] to [DATE]. [DATE] at 14:19, she weighed 117.0 pounds (#) [DATE] at 12:55, she weighed 116.4 # [DATE] at 12:05, she weighed 117.2 # (a 4% weight loss from the ,[DATE] to [DATE]) [DATE] at 14:14, she weighed 122.2 # [DATE] at 17:04, she weighed 126.0 # [DATE] at 9:22, she weighed 143.0 # (an 11.89% weight loss from ,[DATE] to [DATE]) [DATE] at 10:05, she weighed 147.6 # [DATE] at 14:44, she weighed 148.2 # 3. Facility's response to Resident #1's weight loss Record review and interview revealed that although the resident's weight loss was identified in early May, interventions to address it were neither timely, effective, nor consistently implemented. Likewise, interventions were not modified as the resident continued to lose weight. a. Record review A doctor's note, dated [DATE], indicated the resident was seen for depression and weight loss. The orders for the weight loss were to recheck labs for the resident and to order a dietary consultation. The treatment plan revealed the patient was on isolation due to social coronavirus pandemic. The patient's roommate recently passed away. The doctor ordered 10 mg [MEDICATION NAME] with the associated [DIAGNOSES REDACTED]. -However, the resident did not see the dietician until [DATE] (see below), and from ,[DATE] to [DATE], the resident's weighed dropped 8.8 # or 9 % in two weeks. A MDS signed on [DATE], revealed the resident was not on a prescribed weight loss program and had a weight loss of five percent or more in the last month. -However, record review revealed no updates to the resident's [DATE] care plan, with preferences, directions to staff to offer alternates, or discussions with the resident's power of attorney (POA) or IDT on effective ways to promote the resident's intake. In addition, there was no evidence in the resident's care plan regarding the resident's depression, how staff might address it, and whether it was a factor in her weight loss. The care plan history dated [DATE] was revised by registered dietician (RD). It included the resident required meal assistance with reminding and cueing at meal times. She said the resident was a nutrition risk that was likely due to depression. The RD offered the resident was on a regular diet. A note by the dietician following a dietary consult, dated [DATE], revealed the resident was reviewed at the nutritional risk meeting and was at risk for weight loss. She was on a regular diet with no restrictions. She required cueing and encouragement to eat. The resident had refused the nutritional supplements. -However, the dietician's orders, also dated [DATE], read the resident was to be offered the supplement Ensure twice daily, in addition to snacks three times per day for weight loss and weights weekly. Review of the medication administration record (MAR) for [DATE] indicated the resident drank the supplement on only two days following the [DATE] order, refusing the supplement the rest of the month. There was no evidence staff investigated the resident's refusals or offered a different type of supplement in order to encourage intake. A nutrition note beginning [DATE] documented the resident's food intake from [DATE] back 14 days to [DATE]. It revealed poor intake. Specifically, the resident ate ,[DATE]% of food for 8 of the 14 days for breakfast, 25 to 50% on 2 of the 14 days for lunch, and refused to eat dinner (0%) for 9 of the 14 days. It also revealed the resident refused snacks on 100% of those 14 days. -However, there was no evidence staff investigated the resident's refusals, discussed preferences or alternates in order to encourage intake. Likewise, there was no evidence the facility considered her purported depression, its relationship to her weight loss and how staff might intervene. b. Observations revealed Resident #1's intake was minimal and staff failed to offer an alternate meal or encouragement, cueing and reminders to eat as care planned and ordered. [DATE] -At 12:55 p.m. the resident sat in her room with her noon meal in front of her, however, she was not eating. She appeared uninterested in the food and starting falling asleep in her chair. [DATE] -At 12:50 p.m., the lunch meal arrived in the unit. -At 1:06 p.m., Resident #1 received her food. The general nurse assistant (GNA) took the plastic off the resident's plate and left the resident's room. The GNA did not sit with the resident or engage her in conversation. The resident did not receive any encouragement, reminders or cueing from the GSA to eat her meal. -At 1:15 p.m., the resident took two bites of her food. Four minutes later, at 1:19 p.m., the GNA entered Resident #1's room and removed her tray. All of the resident's meal, except for the two bites she had taken, remained on her tray. The GSA did not encourage the resident to eat or offer an alternative meal. -At 1:27 p.m. the licensed vocational nurse (LVN) was informed the resident had not eaten her meal and her tray had been removed without an offer of an alternative meal. The LVN then approached the resident about receiving an alternative meal, like a soup or sandwich, and the resident refused the offer. Several minutes later, at 1:33 pm., Resident #1 ate a piece of dried fruit from a baggie on her table. [DATE] -At 4:40 p.m., the dinner meals arrived in the unit and at 4:58 p.m., Resident #1 received her meal. -At 5:03 p.m. Resident #1 ate one bite of food and declined to eat any more of her meal. She drank 200cc of coffee. Staff did not sit with the resident or engage her in conversation. Staff did not offer her an alternate meal or enter her room to cue or encourage her to eat. The resident was observed continuously until 5:09 p.m., asleep in her wheelchair when her tray was removed from her room. c. Interviews Certified nurse aide (CNA) #1 was interviewed on [DATE] at 3:00 p.m. She said she was familiar with Resident #1. The CNA said Resident #1 was able to feed herself but she needed reminders and cues from staff to eat, stating staff needed to sit with the resident to remind her to eat. She said the resident also needed staff to cut up her food. She further stated the resident had stopped eating after her roommate died . LPN was interviewed on [DATE] at 3:00 p.m. She said she was familiar with Resident #1. She said Resident #1 did not require assistance with eating. She said Resident #1 was a picky eater. She said that Resident #1 liked to sit in the dining room during meals and being isolated from other residents (during the pandemic) had affected Resident #1's appetite. She said Resident #1 usually ate three eggs and toast or cereal for breakfast. The LVN said she would ask management if the resident could have her eggs for breakfast every morning. Resident #1's power of attorney (POA) was interviewed on [DATE] at 2:00 p.m. She said the facility had informed her of Resident #1's weight loss on [DATE]. She stated she was concerned about the resident and she thought Resident #1 was depressed due to the recent death of her roommate. The POA included she had taken snacks to the facility on [DATE] for Resident #1 after she found out about her weight loss. The registered dietician (RD) was interviewed on [DATE] at 9:30 a.m. She said she had discussed Resident #1's decline with the resident's nurse practitioner (NP) and said it sounded like the resident's decline was related to depression, likely due to the death of her roommate who passed away from the COVID-19. She said Resident #1 was close to her roommate and, then, she became isolated from everyone She said the resident's weight loss could have been avoided if the staff had spent more time offering the resident eating assistance. She said she had spoken to the NP about getting an appointment for the resident with a therapist, but nothing had been set up yet. B. Resident #5 1. Resident status Resident #5 was admitted to the facility on [DATE]. According to the CPO, [DIAGNOSES REDACTED]. According to the [DATE] MDS, the resident should be encouraged to eat his meal. His usual body weight per weight chart was 146 lbs. 2. Record review revealed the facility identified the resident was at nutritional risk at admission and losing weight. Orders were entered to monitor the resident and offer supplements. However, the facility failed to modify interventions as the resident continued to lose weight. a. Recognition of weight loss and facility response -On the care plan dated [DATE], shortly after admission, Resident #5 was identified at nutritional risk for weight loss secondary to dementia. The care plan recommended that he ate at least 75% of his meals. The resident should be encouraged to finish his meal. The resident should be offered substitutes if he does not like the meal served. -On [DATE], the resident was seen remotely by a nurse practitioner (NP). The primary concern was abnormal weight loss. The physician reviewed the resident's labs and spoke with the nurses about the resident's condition; the nurses said the resident had been eating and drinking. Monitoring of the resident was ordered. -The care plan dated [DATE] repeated the resident was a nutritional risk and should be monitored for weight loss. The resident was on a regular diet and should be offered snacks in between meals. The resident enjoyed cereal; however, staff had been instructed to offer the regular meals instead of the cereal. The cereal should be the last option. -A nurse's notes dated [DATE] revealed that the resident was a type 2 diabetic and insulin dependent. He was to be offered Glucerna as a meal supplement 2x daily. -The updated care plan dated [DATE] repeated again that the resident was at nutritional risk for weight loss due to dementia. The resident was on a regular diet and had weight fluctuations. No new interventions were documented. -Doctor's orders dated [DATE] included to offer Glucerna 3x times daily. The order also indicated that the resident was to be offered snacks three times daily due to weight loss. Although the daily order for Glucerna was increased, new interventions beyond supplements were not considered. The dietary quarterly assessment dated [DATE] revealed that the resident had a 21% weight loss in the past two months. The assessment indicated that the resident had sporadic meal intakes due to [MEDICAL CONDITION]. None of the care plans and orders referenced above included interventions to address his dementia and what interventions could be considered, given his dementia, to promote weight gain. In addition, there was no evidence the basis for his refusals was investigated by the IDT or NAR committee in order to determine if his refusals could be reversed. Although monitoring of the resident's weight was ordered (see above), there was no evidence the resident's meal intake was monitored and recorded prior to [DATE]. The May record, moreover, revealed orders were not being consistently implemented. Specifically: The nutrition chart for Resident #5 began on [DATE] and ended on [DATE]. It revealed that the resident had eaten ,[DATE]% of 7 meals of the 11 days. He had eaten 26 to 50 % of 8 meals of the 11 days. He ate 75% for 3 meals and had refused to eat 6 of the meals of the 11 days. The nutrition chart revealed that the resident was offered snacks on a daily basis only once a day which the resident refused to eat. b. The resident's weight loss over a period of six months. [DATE] 12:53 144.3 # (from [DATE] to [DATE], a 21% weight loss) [DATE] 13:35 144.8 # [DATE] 14:44 145.2 # (from [DATE] to [DATE], a 9% weight loss) [DATE] 12:43 136.2 # [DATE] 10:58 150.6 # [DATE] 13:14 154.8 # [DATE] 09:25 157.4 # (from [DATE] to [DATE], a 9% weight loss) [DATE] 13:48 168.0 # [DATE] 14:55 164.0 # [DATE] 08:12 166.6 # [DATE] 05:10 170.0 # [DATE] 10:18 171.1 # [DATE] 12:01 174.4 # [DATE] 09:45 175.8 # [DATE] 11:44 174.1 # [DATE] 14:49 173.4 # [DATE] 11:25 172.4 # [DATE] 11:09 175.0 # 3. Observations revealed staff failed to take steps to promote the resident's nutritional status. Staff failed to offer Resident #5 his meal on one occasion, and on another occasion, failed to offer an alternate meal when he refused to eat the meal served. [DATE] (noon meal) -At 12:55 p.m., LPN #1 took food into Resident #5's room. He was asleep and she did not try to wake the resident up for lunch. -At 12:57 p.m., the LPN took the resident's food and left his room. She wrapped the food up and placed it in the refrigerator. She said she would offer it to him later when he woke up. -At 1:35 p.m., Resident # 5 woke up and came out of his room. The LPN did not offer Resident #5 his meal, but rather, gave him a strawberry drink supplement, instead of his meal. He drank 50% of it. Resident #5 was not offered a snack or anything else to eat and at 2:00 p.m., he went down the hall and back to his room. [DATE] -At 4:40 p.m., the dinner meals arrived in the unit. Three minutes later, Resident #5 was observed going down the hall in a wheelchair, asking about dinner. He then returned to his room to eat his dinner. However, after taking two bites of his meal, he refused to eat anymore of his meal, stating the food did not taste good. -At 4:50 p.m., staff picked up the resident's tray. Resident #5 was not offered an alternate meal. 3. Interviews CNA #1 was interviewed on [DATE] at 2:46 p.m. She was familiar with Resident #5. She said Resident #5 needed total assistance for dressing and toileting. She said the resident sometimes had behavior problems and staff had to let the resident cool down before approaching him. She said that Resident #5 was a picky eater. She said Resident #5 would usually drink the supplement the nurses gave him but did not like to sit in his room and eat. She said the resident should be reminded to eat several times during the meal. LPN #1 was interviewed on [DATE] at 3:10 p.m. She said she was familiar with Resident #5. She said Resident #5 suffered from dementia. She said he looked around for his son to come see him. She added that Resident #5 was diabetic. He was prescribed Glucerna three times per day as of [DATE]. She said she tried to offer his meal before he got the supplement. She added he liked ham and cheese sandwiches and she would get one for him when he asked. She said staff let him wake up on his own because he was more cooperative that way. She said his doctor was notified about his weight loss on [DATE] and a physician visit was requested and conducted [DATE]. She said Resident #5 was an independent eater. III. Resident #3 Resident #3, younger than [AGE] years old, was admitted on [DATE]. According to the [DATE] computerized physician orders [REDACTED]. The [DATE] minimum data set (MDS) assessment revealed the resident was moderately cognitively impaired with a brief interview for mental status (BIMS) score of eight out of 15. The [DATE] MDS assessment revealed a BIMS score was not conducted. She required supervision set-up for eating. A. Observations Resident #3 was observed during the noon meal on [DATE] at 12:54 p.m. The resident sat on her bed, with the meal tray next to her on the mattress. The resident had consumed approximately 50% of her meal and said the meal was God awful. The resident said she had not been offered an alternative meal. B. Record review 1. Care plan The care plan last revised on [DATE] showed the resident was at nutrition/hydration status as evidenced by [DIAGNOSES REDACTED]. Interventions included: -Encourage good meal intakes and offer substitutes for uneaten food; -Monitor and record all food and fluid intake; -Monitor weight and weight trends per facility protocol; and -Administer supplements as ordered. The care plan had not been updated since the revision date of [DATE]. The care plan did not indicate family and/or the physician were to be notified of any significant weight changes. 2. physician's order [REDACTED]. According to the [DATE] CPO orders included: -Boost (nutritional supplement) eight oz offer after breakfast with a start date of [DATE] -Regular diet regular texture with thin consistency fluids with a order date of [DATE]. -Speech therapy (ST) to evaluate the resident for cognition, recent weight loss, poor food intake, environmental changes at meals with a start date [DATE]; and -Registered dietician (RD) to evaluate and treat for protein with a start date of [DATE]. Review of the February 2020 medication administration record (MAR) documented the resident drank 237 milliliters (ml) of the Boost supplement on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and 2/ 23 and eight ml on ,[DATE]. The MAR indicated the resident refused the supplement 18 days during the month of February. The remaining three days in the month of February documented either the supplement was given without the quantity documented or ' other/see progress notes ' was indicated; however, review of the progress notes for the remaining days did not reveal a progress note of refusal by the resident and/or an explanation as to why the supplement was not consumed. Review of the [DATE] MAR documented the resident drank 237 ml of the Boost supplement on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE] and 120 ml on ,[DATE] and ,[DATE]. The remaining 19 days in the month of February documented either the supplement was given without the quantity documented or the resident refused the Boost supplement. Review of the progress notes revealed there was no indication that the resident was offered and refused the supplement. Review of the [DATE] MAR documented the resident drank 236 ml of the Boost supplement on ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. The MAR indicated the resident refused the supplement four times during the month on ,[DATE], ,[DATE], ,[DATE], and ,[DATE]. The remaining 22 days in the month of April documented ' other/see progress notes ' ; however, review of the progress notes for the remaining days did not reveal a progress note of refusal by the resident and/or an explanation as to why the supplement was not consumed. The DON was interviewed on [DATE] at 4:30 p.m. The DON said when the MAR showed other/see progress notes, that meant a progress note needed to show a note to indicate the reason the Boost was not consumed. The medical record failed to show any progress notes in regards to the refusal of the Boost supplement. Furthermore, there were no notes to indicate that the RD and physician were notified of the refusal and no evidence staff investigated the resident ' s refusals or offered a different type of supplement in order to encourage intake. 3. Weight loss The resident matrix provided by the DON on [DATE] at 12:17 p.m., showed Resident #3 had excessive weight loss without a prescribed weight loss program. Review of the medical record revealed the resident had a severe weight loss at 22.41% over a six month period between [DATE] and [DATE]. The weights were as follows: -[DATE]: weight of 110.8 pounds (21.97% weight loss x one month; 22.41% weight loss x six months) -[DATE]: weight of 110.4 pounds (22.25% weight loss x one month; 22.69% weight loss x six months) -[DATE]: weight of 119 pounds (16.2% weight loss less than one month; 12.76% weight loss x six months) -[DATE]: weight of 142 pounds -[DATE]: weight of 134 pounds -[DATE]: weight 135 pounds -[DATE]: weight of 124.5 pounds -[DATE]: weight of 127.8 pounds -[DATE]: weight of 132.4 pounds -[DATE]: weight of 142.8 pounds -[DATE]: weight of 136.4 pounds -[DATE]: weight of 130 pounds There was no record of the resident being reweighed or a progress note added to the residents medical record, as outlined in the Weight Pathway Policy, when there was a discrepancy of +/- three pounds from the prior documented weight. The most recent dietary quarterly assessment dated [DATE] was reviewed. It revealed .The resident tolerated a regular diet with a food intake of ,[DATE]%. The resident was provided supplements of boost, [MEDICATION NAME] (vitamin D), and potassium and would be provided with fortified foods. Current body weight was 132.4 lbs on [DATE] with a body mass index (BMI) of 19.5. The residents ideal body weight was 135 lbs. The assessment indicated the resident had a significant weight change quantified as >5% x one month, >7.5% x three months, >10% x 180 days. Resident was seen by ST recently and noted the resident needed to be cued for meals and encourage to sit at table for increased intake. IDT interventions included weekly weights on resident x4 weeks . Review of the [DATE] CPO did not reveal weekly weights had been ordered nor were they documented on the medication administration record (MAR) or treatment administration record (TAR). The interdisciplinary team (IDT) note for weight and skin, completed by the dietary manager (DM) on [DATE] revealed the residents previous weight was 143 lbs on [DATE] and her current weight was 132.4 lbs on [DATE]. The IDT note documented there was not a need to reweigh the resident, even though the Weight Pathway Policy indicated a resident should be reweighed if there was +/- three pounds from the previous weight. The IDT note documented the resident was triggered for weight loss and will monitor for three more weeks or until stable. Review of the medical record did not reveal documentation for food or fluid intakes for the resident from February 2020 to [DATE]. The DON was interviewed on [DATE] at approximately 11:00 a.m. The DON said she was unable to provide copies of the meal intakes for Resident #3 for the months of February 2020 though [DATE], as they were not completed. She said she had now provided training to the staff to record food intake. Review of the progress notes revealed: -[DATE] Weight Change Note: .WEIGHT WARNING: Value: 130.0 .Vital Date: [DATE] .-5.0% change ( 13.9% , 21.0 ), -7.5% change ( 13.3% , 20.0 ), -10.0% change ( 10.3% , 15.0 ); Reweigh requested. Continues to come to the main dining room (MDR) for meals. Appears at her baseline. No other significant changes observed . -[DATE] nurse practitioner (NP): .The patient was seen for abnormal weight loss. Her weight is down to 136.4 lbs. She is on a regular diet. Staff report she is eating and drinking. She was seen by dietary. She is on a supplement. Abnormal weight loss recurrent. Continue to monitor. RD to continue to follow. Continue supplement. Follow-up next month . -[DATE] dietary: .Quarterly assessment: Resident continues a regular diet with regular texture and thin liquids .has a history of variable weights, which may be related to her mood she has had some weight variance that has somewhat recovered in December .resident can and does express her food prefere (TRUNCATED)

Based on observation, interview and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically: Record review and interviews with staff involved in nutrition and hydration management revealed an ineffective system in implementing facility policy on and surrounding nutrition and in maintaining acceptable nutritional parameters These failures contributed to a pattern of residents experiencing severe weight loss. Cross Reference F 692 H; F 803 F 806 F 809 Findings include: A. Current findings in area of quality of care - Failure to ensure facility policy was implemented to identify, prevent, asses and treat weight loss for Residents #1, #2, #3, #4, #5 and #6. 1. Facility Policy A. The Nutrition (Impaired)/Unplanned Weight Loss - Clinical Protocol revised September 2012, was provided by the nursing home administrator (NHA) on 6/4/2020 at 9:35 a.m. It revealed in pertinent part: The nursing staff will monitor and document the weight and dietary intake of residents in a format which permits readily available comparisons over time. The staff and physician will define the individual ' s current nutritional status and identify individuals with anorexia, recent weight loss, and significant risk for impaired nutrition. The threshold for significant unplanned and undesired weight loss will be based on the following criteria: a) 1 month - 5% weight loss is significant; greater than 5% is severe, b) 3 months - 7.5% weight loss is significant; greater than 7.5% is severe, c) 6 month - 10% weight loss is significant; greater than 10% is severe. The physician, with the help of the multidisciplinary team (IDT), will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. The physician will consider whether any assessment including additional diagnostic testing is indicated to help clarify the severity or consequences of weight loss and/or impaired nutrition. The physician will review possible causes of weight loss with the nursing staff and/or dietician before ordering interventions. The physician (or staff, based on a discussion with the physician) will document relevant medical observations and, regarding the nature, severity, causes, and consequences of impaired nutritional status, especially in complex situations or where multiple, active causes may co-exist. The staff and physician will identify any pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes. Treatment decisions should consider all pertinent confirmation or evidence, such as food intake and overall condition. Nutritional needs: The dietician will help the physician determine the appropriate diet for the resident based on the resident ' s degree of nutritional impairment. Environmental factors: Staff will ensure that the food served to the resident has an appealing aroma, flavor, form, temperature, and appearance. Supplementation: Strategies to increase a resident ' s intake of nutrients and calories may include fortification of food, providing between-meal snacks and/or nutritional supplementation. The physician and staff will closely monitor residents who have been identified as having impaired nutrition or risk factors for developing impaired nutrition. Such monitoring may include: Evaluating the care plan to determine if the interventions are being implemented and whether they are effective in attaining the established nutritional and weight goals; Evaluating the resident ' s response should be based on defined criteria for improvement/worsening of nutritional status; Observing for and documenting any sustained decline in appetite and/or food intake; and Observing for and reporting significant weight gain and/or loss. B. The Weight Pathway Policy was provided by the NHA on 6/4/2020 at 9:35 a.m. It read, in pertinent part: In the event the weight of the resident varies +/- three lbs from the prior weight, the restorative aide must solicit the treatment and lead to witness a reweight. In the event the weight remains the same it will be documented, with two separate entries, and reweighed the following day. In the event the weight still varies the following day, a progress note will be made, the doctor and registered dietitian (RD) made aware of change, and change of condition process started for nurses where they document every shift on the encouragement of fluids if applicable, intake of residents, or any change in eating patterns. The interdisciplinary team (IDT) will meet to review weights. The weight summary report should be pulled with a six month lookback for review. These will be the weights to review, no other report to be utilized. It is the expectation that the director of nursing (DON) would attend the monthly weight meeting. Weekly weights determined in the meeting were based on criteria of residents with greater than 3 lbs from the last weight, 5% in 30 days, 7% in 90 days or 10 % in 180 days. All interventions are to be care planned in the moment at IDT for any resident that is added for review every week. Nutrition at Risk (NAR) meetings should include minimally the Director of Nursing, and the dietary manager, weekly. The Dietician, Social Services, activities and administrator should be included monthly in the initial meeting for the month. Ensure actual intakes are reviewed prior to the NAR meeting and every day. Use the alert on your dashboard as a way to guide the staff to be proactive. That information is something the dietary manager should assess. Minimum intake for fluids, food, and protein will be based on your Dietician ' s assessment so please ensure documentation is occurring. When performing a NAR review and determining interventions ensure you recap what was previously tried, review the care plan and ensure implementation is plausible. 2. Cross reference F692H. Facility administration failed to timely and comprehensively identify, assess, prevent severe weight loss. These failures created situations that resulted in a pattern of harm. -Observation, record review, and interviews with staff, health professionals, and residents demonstrated the facility did not have an effective system in place to implement preventive measures for residents who had been assessed to be at risk for weight loss. Nursing staff did not consistently provide meal assistance, ensure weights were accurate, notify the responsible party of severe weight loss, involve the registered dietitian timely, and did not offer alternatives when the meal was not consumed. -Severe weight loss was not monitored or interventions were not implemented timely. The facility did not have formal weekly nutrition at risk (NAR) meetings, and assessments completed. -Record review and interviews with staff involved in nutrition management revealed an ineffective system in implementing facility policy (above) and in how to identify, implement, monitor, and modify interventions (as appropriate), consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards of practice, to maintain acceptable parameters of nutritional status. Resident #1 experiencinced an 18 percent (%) (severe) weight loss Resident #5 experiencing a 21% (severe) weight loss Resident #2 experiencing a 9.71% (severe) in three months Resident #3 experiencing an 11.85% (severe) weight loss in three months Resident #4 experiencing a 9.57% weight loss in three months Resident #6 experiencing a 6.82% (severe) weight loss in one month. The facility's failure to identify its systemic issues in its management of residents at risk , including the lack of preventative measures for at risk residents, the lack of formalized weekly NAR meetings, provide meal assistance, identify, implement, monitor, and modify interventions (as appropriate), consistent with the resident ' s assessed needs, choices, preferences, goals, and current professional standards of practice, to maintain acceptable parameters of nutritional status, contributed to a pattern of residents having severe weight loss. Interviews The director of nurses (DON) was interviewed on 6/1/2020 at 3:05 p.m. The DON said she had worked at the facility since January 2020. She said that she was aware there were residents who had severe weight loss. She said prior to the 5/21/2020 NAR meeting with the RD, the NAR meetings were informal and she said that was her error. She said they did not have an RD to bounce things off of. She said the previous RD was asked to review, however she did not ask again, when they were not completed and did not follow up. The nursing home administrator (NHA) was interviewed on 6/1/2020 at approximately 4:00 p.m. the NHA said he was aware there were residents who had weight loss. The NHA said the facility had a RD who did not respond to requests, and ended his contract abruptly on 4/17/2020. He said the corporation did not have any other RD ' s which he could utilize to assess residents. The registered nurse consultant was interviewed on 6/1/2020 at 5:26 p.m. The RNC said he had been working for the facility only a few months. He said 5/16/ 2020 he had identified there were a lot of weight discrepancies. He said he had been working on the weights since. He said the residents were to be re-weighed if there was a plus or minus of three pounds. However, regardless, of the weight when a weight loss was suspected, the physician and the RD needed to be contacted. The director of operations was interviewed a second time on 6/3/2020 at 11:00 a.m. She said the facility did have access to an RD who worked for one of the related facilities, and that the RD was always available to assist. She said she would arrange for a dietary manager from another building to provide training to the dietary staff. The NHA and the director of operations were interviewed on 6/3/2020 at 11:45 a.m. The NHA said he was aware there were residents who had weight loss. He said the residents were reviewed in the weekly NAR meetings, and that timely interventions were put into place. He said he was not aware snacks were not always available for residents. The DON was interviewed on 6/5/2020 at approximately 11:00 a.m. The DON said she was unable to provide copies of the meal intakes for Resident #1,#2, #3, #4, #5, #6 for the months of February 2020 though June 2020, as they were not completed. She said she had now provided training to the staff to record food intake. The MD was interviewed on 6/5/2020 at 11:45 a.m. The MD said he had been the MD for the facility for the past two years. He said he attended QAPI on a monthly basis. He said prior to COVID 19 he would come into the building at least five or six times a month. He said that he followed the corporation policies. He said every month in the QAPI meetings, he reviewed different reports, such as the safety fall reports, skin reports, resident council and the nutrition at risk. The MD said at the last QAPI meeting weight loss was discussed. He said that the team discussed the current challenges of staffing, and the COVID 19 restrictions. He said that some [DIAGNOSES REDACTED]. He said he did not direct the care, but that it was a group discussion. The new team had challenges and together they worked collaboratively. He said from the team discussion, he did not follow up on any suggestions. He said he had good faith and the team had best intentions, and he did not think he needed to follow up. He said at the next QAPI meeting he will get a recap of what the facility did as follow up.

Based on observation, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents, affecting two (#1 and #8) residents reviewed of the nine sample residents. Specifically, the facility failed to: -Adequately meet Resident #1 ' s need for supervision. Resident #1 was severely cognitively impaired and independently ambulatory with recent [MEDICAL CONDITION] activity. Record review revealed he consistently engaged in exit seeking, some days constantly, frequently urinated and defecated in his room and common areas of the facility, as well as engaged in other unsafe behaviors, such as taking food off residents ' plates and dirty plates, putting metal items in electric outlets, and wandering into other residents ' bedrooms. The facility failed to provide Resident #1 the level of supervision his condition and behaviors required. This failure created the likelihood of serious adverse outcome to Resident #1 and other facility residents if not immediately corrected. The facility also failed to identify and care plan Resident #8 ' s risk for wandering and eloping and initiate interventions for the resident ' s safety. Findings include: I. Immediate jeopardy A. Situation of immediate jeopardy Resident #1, severely cognitively impaired and independently ambulatory, with recent [MEDICAL CONDITION] activity, exhibited behaviors likely to cause serious adverse outcomes, including attempting to elope from the facility over a dozen times and attempting to place metal feeding utensils inside electrical outlets. The resident also had a grand mal [MEDICAL CONDITION] on 4/4/2020 while in the smoking area, which had the potential for serious adverse outcome if staff had not witnessed the [MEDICAL CONDITION] or if the resident had been in a location where there had not been any witness due to his frequent elopement attempts from the facility. Resident #1 ' s condition and behaviors and failures in the facility ' s response, created the likelihood of serious adverse outcome if the facility ' s response was not immediately corrected. B. Imposition of immediate jeopardy On 4/22/2020 at 8:36 p.m., the nursing home administrator (NHA) was informed the facility failed to provide supervision to a known eloping resident with poor safety awareness, which created a situation of immediate jeopardy with the potential for serious adverse outcome for Resident #1. C. Facility response to immediate jeopardy On 4/23/2020 at 5:40 p.m., the regional director of operations (RDO) submitted a final abatement plan (draft #5) to the Colorado Department of Public Health and Environment (CDPHE) to remove the immediate jeopardy situation. The abatement plan read: Resident #1 (#2573) was reassessed for wandering or elopement on 4/22/2020 and found to still be at high risk for elopement. The resident was placed on one to one at 8:55 p.m. on 4/22/2020 to ensure he did not exit the building unaccompanied. Staff will be assigned the one to one observation/attendance as their sole responsibility for the shift. Shifts will vary from eight hours to twelve, determined by availability, with staff in house or outside staffing agencies. Interventions for Resident #1 will include encouraging him to come back into the building gently motioning him to follow, walking with him outside, offering snacks or a coke, engaging him in games. Resident #1 will remain one to one supervision and assistance until he is transferred to another facility. Education with regards to elopement and wandering and constant supervision for Resident #1 current staff and any agency staff with regards to supervision of Resident #1 and elopement interventions, will occur prior to them starting their next shift, done as they are assessed for entry into the building. An education print out will be provided to current staff and agency staff upon their arrival for them to keep on their person, as well as education they will sign attesting to their knowledge of the following: The definition of wandering and elopement Who has wander guards Interventions for Resident #1 and need for constant supervision Plausible interventions for other residents who are at risk for wandering or eloping All exits for the building were assessed on 4/22/2020 to determine if there were areas of vulnerability for residents at risk to exit. D. Removal of the immediate jeopardy: On 4/23/2020 at 6:00 p.m. the NHA and RDO were notified the immediate jeopardy had been removed based on review of the facility ' s abatement plan. However, deficient practice remained at an E level. II. Resident #1 A. Resident status Resident #1, age less than 65, admitted [DATE]. According to the April 2020 computerized physician orders [REDACTED]. According to the 2/6/2020 minimum data set (MDS) assessment, the resident ' s cognitive function was severely impaired with a brief interview for mental status (BIMS) score of two out of 15. The resident had behaviors not directed toward others including physical symptoms such as disrobing in public, urinating and defecating in public, and wandering one to three days during the assessment period. The resident was independent with walking in the room and corridor. He required minimal assistance of one person for dressing, toilet use and personal hygiene. According to the April 2020 computerized physician orders [REDACTED]. Review on 4/30/2020 of the behavior monitoring record revealed for February 2020, March 2020 and April 2020, the resident was to be monitored for exit seeking behaviors every shift. B. The facility was aware Resident #1 exhibited behaviors (exit seeking, urinating and defecating throughout the facility, digging through garbage, eating off dirty plates, and attempting to put metal items in electric outlets) which placed him as well as other facility residents at risk for serious adverse outcomes. Nursing progress notes from June 2019 to April 2020 documented increasing incidents of exit seeking, inappropriate urination and defecation, and instances of aggressive and inappropriate behaviors toward other residents and staff. 1. June 2019 to January 2020 progress and interdisciplinary notes documented increased exit seeking, unsafe and intrusive wandering, unsanitary and aggressive behaviors with an identified need beyond line of sight supervision, to constant one to one supervision in mid-January, due to agitation and physically aggressive, confrontational and intimidating behavior toward residents and staff. -A 6/21/2019 nursing progress note revealed the resident was found outside smoking after his wander guard alarm alerted staff that he had exited the facility. -A 8/2/2019 interdisciplinary team (IDT) risk management progress note revealed the resident was found walking down the street by staff on 8/1/2019 at 6:46 p.m. The note read staff checked his wander guard which was functioning. He was reminded he cannot leave the facility without supervision. -An 11/19/2019 nursing progress note revealed the resident defecated in the sink and smeared feces on the bookcase, books, floor and clothing. The note read he was approached by three staff members after being resistive to care without success. -An 11/23/2019 nursing progress note revealed the resident was arguing with another resident who accused him of hitting her in the mouth. The note read the residents were separated and Resident #1 was provided one to one supervision until 11/24/2019. The note further read the resident was exit seeking, going outdoors multiple times an hour, often difficult to redirect and resistive to personal care. The care plan was updated to include: redirect and assist the resident away from confrontational situations. -An 11/24/2019 nursing progress note revealed the resident had multiple exits outdoors, greater than 16 in a shift with occasional verbal outbursts when redirected and continued resistance to personal care. -An 11/26/2019 nursing progress note revealed the resident was exiting outdoors literally every three to five minutes, was difficult to redirect and became agitated with verbal outbursts. It indicated he walked through the dining room, taking food off other residents ' plates and urinated on the floor in his room. It also revealed the resident took a newspaper out of another resident ' s hands and hit them on the head with the newspaper. The care plan was updated to include: assist the resident to a quieter calmer area of the living environment to decrease stimulation. -An 11/27/2019 nursing progress note revealed the resident repeatedly exited doors and became increasingly difficult to redirect indoors. It read he wandered through the dining room taking food and belongings from other residents. The care plan was updated to read: keep the resident in line of sight while out of the room related to history of aggression towards other residents and seek alternative placement with memory care focus, decreased stimulation and a secure unit. -An 11/28/2019 nursing progress note revealed the resident repeatedly exited the building and was difficult to redirect back indoors. It indicated he was urinating on the floor, was confrontational and quick to anger. -An 11/29/2019 nursing progress note revealed the resident did not sleep during the night shift, wandering and exit seeking and was difficult to redirect. -An 11/30/2019 behavior progress note revealed the resident defecated on the floor in his room and smeared it around on the floor. -A12/4/2019 nursing progress note revealed the resident was exiting out the door to the smoking patio throughout the shift but could be redirected back into the building. -A 12/8/2019 nursing progress note revealed the resident was found without pants on in his room with urine on the floor and feces on the bed and then wandered outside without pants. The note read the resident went out the main door and the door at the end of the hallway, setting off the alarms. -A 12/10/2019 nursing progress note revealed the resident exited outdoors multiple times during the shift and was redirected back into the building after multiple attempts. The note further read the resident spread feces throughout his bedroom floor with his feet and urinated in the hallway and was resistive to care. -A 12/16/2019 nursing progress note revealed the resident kept going outside without socks. -A12/25/2019 nursing progress note revealed the resident frequently walked outdoors by the activities area, the front door, the smoking area and Maple Hall. It read he was difficult to redirect and required one to one monitoring for a majority of the shift to prevent him from confronting other residents. -A 12/28/2019 nursing progress note revealed the resident was continually walking out the smoking area door, with no coat, socks or shoes on. It indicated he continually attempted to go out locked/alarmed doors, setting off alarms on Maple hall, the sun room, the smoking area, activities area and the front door, becoming verbally aggressive and physically intimidating with raised fists, raised voice, and cursing. The note revealed the resident opened other residents ' doors, wandered in and upset them. The note further read he rummaged through the garbage, ate leftover food off dirty dishes and required constant monitoring due to exit seeking, setting off door alarms, and wandering into other residents ' rooms. -A 12/29/2019 nursing progress note revealed the resident was awake the entire night shift, wandering into other residents ' rooms and exit seeking, setting off alarms. -A 12/31/2019 nursing progress note revealed the resident was continuously exit seeking and walking outdoors without socks and shoes on. It read the resident was taking food and beverages off other residents ' tables and became angry and combative when redirected. -A 1/1/2020 nursing progress note revealed the resident had continuous exit seeking during the shift wearing only a soiled brief. It indicated he defecated in the sink and urinated in the hall, allowing staff to assist with personal care after multiple approaches. -A 1/2/2020 nursing progress note revealed the resident had continual exit seeking to the smoking patio and twice through alarmed exit doors. It indicated he urinated on the floor in his room and was difficult to redirect. -A 1/4/2020 nursing progress note revealed the resident was continually exit seeking but was able to be redirected back into the building. The note read he urinated on the floor of the chapel and his room and he was taking food, plates, utensils and glasses from other residents ' tables. -A 1/7/2020 nursing progress note revealed the resident had been urinating on the foosball table in the chapel and stuffed his sandwich in the hole on the table. -A 1/9/2020 nursing progress note revealed the resident was repeatedly exit seeking and was difficult to redirect. -A 1/10/2020 nursing progress note revealed the resident was exit seeking throughout the shift but was easily redirected without behaviors. -A 1/11/2020 nursing progress note revealed the resident was exit seeking during the shift and was difficult to redirect at times. -A 1/12/2020 nursing progress note revealed the resident continued with constant exit seeking, triggering alarmed doors which woke other residents. It indicated the resident wandered into other residents ' rooms, even when the doors were closed. The resident continually exited through the smoke area door, triggering the alarm with no coat or footwear on in cold weather. It indicated the resident dug through the garbage and ate leftover food off dirty plates. The resident urinated on a sit to stand lift on Willow hall and on the floor in the chapel. It indicated the resident was ambulating throughout the facility without any clothes on and was difficult to redirect, becoming agitated, angry and physically intimidating, raising his fists while approaching the staff at a close proximity. The note read the resident required constant one to one supervision to ensure he did not exit the building and to ensure his safety as well as the safety of other residents. -A 1/13/2020 nursing progress note revealed the resident had continuous exit seeking with no shoes on and defecated in the smoking area then wandered in the hall wearing soiled pants. The note read the resident was resistive to care. -A 1/15/2020 nursing progress note revealed the resident was constantly exiting through the smoking area door and end of Maple hall, triggering the alarms, without a coat, socks or shoes. The note read he urinated in various locations on Willow hall three times and in the chapel once. The note further read, the resident required constant one to one to ensure he did not exit the building and to ensure his safety as well as the safety of other residents; however, staff was not always available to provide one to one needed to shadow the resident as he wandered, was exit seeking and to make sure he did not urinate or defecate in inappropriate places throughout the facility. Another nursing progress note on 1/15/2020, read staff witnessed the resident attempting to place metal silverware inside electrical outlets and were able to redirect him. The staff also witnessed the resident drinking directly from the pitchers on the breakfast drink cart and pouring artificial sweetener packets directly into his mouth. It indicated the resident became easily agitated, physically aggressive and intimidating when attempting to redirect. -A 1/16/2020 nursing progress note revealed the resident had frequent exit seeking, as well as urinating in the hallway, room, chapel and lobby and defecating in his room. It read he was walking in the hallways naked and was resistive to care. 2. February 2020 to April 2020 progress and IDT notes revealed Resident #1 continued to exit seek frequently, continuously, although the behavior monitoring records (reviewed 4/30/2020) for February 2020, March 2020 and April 2020 documented no behaviors and a 2/2/2020 Wandering/Elopement Risk Assessment assessed the resident at a moderate risk for wandering. In addition, the resident ' s unsafe behaviors noted above also continued. -A 2/5/2020 nursing progress note revealed the resident had frequent exit seeking, setting off alarms, walking in the halls at a rapid pace with a forward leaning gait. -A 2/6/2020 nursing progress note revealed the resident had frequent exit seeking. -A 2/14/2020 IDT risk management progress note revealed the resident had a behavior of participating in poor eating etiquette during dining meal times by reaching in other residents ' plates on 2/13/2020 at 5:50 p.m. The resident was to receive meals prior to dining meal times to provide a calmer environment. -A 2/19/2020 social service progress note revealed the resident was observed attempting to exit seek and was able to be redirected. -A 2/21/2020 behavior progress note revealed the resident was continuously exit seeking and urinating on the floor in his room. He was redirected with little success. -A 2/23/2020 nursing progress note revealed the resident was observed sitting on the floor in the dining room and then laying down with twitching motions noted to his upper extremities that stopped after 15 to 20 seconds. -A 2/25/2020 nursing progress note revealed the resident was attempting to go outside unattended without shoes or a jacket, but was easily redirected. -A 2/28/2020 behavior progress note revealed the resident had been wandering throughout the facility and had gone out several times setting off the alarms. It indicated he was voiding on the floor in public areas then laying down on the wet floor. He was difficult to redirect and would get combative with the staff. -A 2/28/2020 nursing progress note revealed the resident continued to do in and out of doors, urinated and defecated on his bedroom floor, and required frequent monitoring and guidance by multiple staff. -A 3/7/2020 nursing progress note revealed the resident was wandering in the hallways and was difficult to redirect away from the sun room where he attempted to go out the door. -A 3/8/2020 nursing progress note revealed the resident was wandering the hallways onto the other unit and exited several times. It indicated he urinated on his bedroom floor and was difficult to redirect. -A 3/10/2020 nursing progress note revealed the resident had repeated exit seeking and voided in the chapel. -A 3/11/2020 nursing progress note revealed the resident had active exit seeking in the early evening. The note read he exited onto the smoking patio 12 times in one hour. -A 3/13/2020 nursing progress note revealed the resident wandered in the hallways, urinated on his bedroom floor several times and defecated in inappropriate areas. -A 3/14/2020 nursing progress note revealed the resident went outside in the smoking area walking the fenced area and when staff went to recheck on the resident, he was no longer in the fenced area. It indicated the administrative staff immediately went and searched the grounds and escorted the resident back to the facility. The wander guard was in place and working properly. The resident was placed on safety checks and was to be kept in the facility or monitored outside with staff at all times. -A 3/15/2020 nursing progress note revealed the resident continued to exit seek but was able to be redirected. -A 3/16/2020 nursing progress notes revealed the resident continued on frequent checks due to elopement. It indicated the resident continued to make several attempts to exit the building going out the alarmed door in the dining room and the door to the smoking patio but was able to be redirected without any issues or concerns. -A 3/18/2020 IDT risk management progress note revealed the resident was put on 15 minutes safety checks and when he was sleeping, staff were to sit in the hall to monitor the door to his room to ensure the resident did not get out of the facility. It indicated the resident was redirected when he tried to go outside or staff went outside with the resident. -A 3/21/2020 nursing progress note revealed the resident defecated on his bedroom floor. -A 3/23/2020 nursing progress note revealed the resident attempted to leave out the back door near the sunroom, causing the alarm to go off. -A 3/28/2020 nursing progress note revealed the resident was going in and out of the smoking patio multiple times with frequent visual monitoring being done during the shift. -A 4/4/2020 nursing progress note revealed the resident had a grand mal [MEDICAL CONDITION] about one and a half minutes while out of the smoking patio with residents and a nurse. -A 4/6/2020 nursing progress notes revealed the resident was up and pacing the television room and tried to go out the smoker door but was able to be redirected. -A 4/6/2020 behavior progress note revealed the resident exited the smoke area and proceeded to walk down the road. The note read staff was able to retrieve the resident and return to the building without difficulty. -A 4/7/2020 nursing progress note revealed the resident had door seeking behavior, wandering on the halls and lying on the floor. -A 4/11/2020 nursing progress noted revealed the resident had exit seeking behavior during the shift and wandering the halls without pants on. -A 4/12/2020 behavior progress note revealed the resident had been very restless and had elopement behavior the entire shift. It read the resident attempted to exit through different doors several times but was able to be redirected. -A 4/13/2020 nursing progress note revealed the resident had been trying to exit, setting off the door alarms multiple times. It indicated that he took his pants off in the hallway. -A 4/14/2020 nursing progress note revealed the resident continued to exit seek numerous times throughout the day shift setting off different alarms throughout the facility. The nurse continued to assist the resident back into the facility. -A 4/18/2020 nursing progress note revealed the resident continued to exit seek numerous times throughout the day setting off alarms in different areas of the facility. Staff were able to redirect the resident back into the facility. -A 4/19/2020 nursing progress note revealed the resident had been setting door alarms off by continued door seeking behavior throughout the night. -A 4/20/2020 nursing progress note revealed the resident was wandering the halls, door seeking through the night setting the door alarms off. -A 4/21/2020 nursing progress notes revealed the resident exited the building by the smoke area and attempted to exit the courtyard area but he was able to be redirected back into the building without altercation. C. Failure to meet Resident #1 ' s need for supervision prior to 4/22/2020 at 8:36 p.m. and notification of immediate jeopardy, creating the likelihood of serious adverse outcome for Resident #1 and other facility residents. 1. Failure to develop and implement effective interventions June 2019 to January 2020 to keep Resident #1 and other facility residents safe from serious adverse outcomes. Record review revealed prior to November 2019, Resident #1 did not have interventions to address his wandering and exit seeking behavior, except for his use of a wander guard. While he had a care plan to address his potential to display unprovoked verbal and physically aggressive behaviors toward others and his episodes of smearing feces and defecating in inappropriate places, there were no interventions to address these behaviors. In November 2019, when Resident #1 ' s exit seeking significantly increased (going outdoors multiple times an hour, going outdoors greater than 16 times per shift, going outdoors literally every three to five minutes, his care plan was updated (line of sight while out of room); however, redirection was the most frequently noted intervention. Yet, neither line of sight nor redirection was effective, as evidenced by subsequent notes in December 2019 and January 2020 (see above) of the resident continuously exit seeking, often without appropriate clothing (no coat or footwear in cold weather). Staff documented ((12/25/19, 1/12/19, 1/15/19) that the resident required one to one monitoring/supervision and/or constant one to one monitoring, but noted in one entry that staff was not always available to provide one to one to shadow Resident #1 as he wandered. While an 11/27/19 note had documented an alternative placement would be pursued, the facility was unable to find appropriate placement and the staff reported one to one was not always available. In addition, there was no evidence the resident ' s behavior care plan was updated with interventions to address his unsafe, unsanitary behavior of defecating and urinating in inappropriate places and opening other residents ' doors and wandering in, behaviors that created a safety risk for both Resident #1 and other facility residents. There was no evidence that line of sight supervision was effective in minimizing these incidents. 2. Failure to develop and implement effective interventions February 2020 to April 22, 2020 to keep Resident #1 and other facility residents safe from serious adverse outcomes. a. Failure to implement plan to supervise Resident #1 in the courtyard as planned or to keep the resident in line of sight (see administrator (NHA) interview below) Record review revealed Resident #1 ' s care plan was updated on 3/14/2020, after the resident left the fenced-in smoking area. It read, The resident will not be outside the fenced courtyard unsupervised. However, a behavior progress note dated 4/6/2020 (see above) revealed the resident exited the smoking area and proceeded to walk down the road before he was retrieved by staff. Observations on 4/22/2020, from 4:35 p.m. to 5:00 p.m. also revealed Resident #1 was not supervised in the courtyard as planned. Specifically: On 4/22/2020 at 4:35 p.m., Resident #1 was not found in his room. The Assistant Director of Nurses (ADON) was observed walking from the 100 hall toward the common/television (TV) area. RN #1 was standing at a medication cart in the common area, with her back to the door that exited to the outside smoking area. No other staff were in the common area prior to 4:40 p.m. as the surveyor exited through the door to the smoking area. The door was not locked and did not alarm when opened. Observations revealed three residents sat at separate tables, smoking. Beyond these residents and off to the left of a walkway, Resident #1 sat on the ground in front of a bench, leaning forward with his forehead resting on a concrete flower pot and his arms at his sides. There was no staff member with him. His left leg was bent underneath him and his right leg was bent at the knee and extended out to his right. He was wearing a long sleeved shirt, pants, and a sock on his left foot. His right foot was bare. His speech was incoherent and he was unable to say why he was sitting on the ground or if he was injured. At 4:41 p.m., the ADON and certified nurse aide (CNA) #1 entered the smoking area and approached Resident #1. As they approached the resident, CNA #1 said, Well (Resident #1), I ' ve been looking all over for you! The ADON said, The nurse said he just came out here. CNA #1 assisted the resident to stand and sit on the bench, then escorted him back into the building to his room. When he approached the door into the building, the alarm sounded, triggered by the resident ' s wander guard bracelet. As the resident and CNA #1 approached his room, Resident #1 kept walking down the hall. The CNA had to stop and direct him to his room. Neither the ADON nor any other licensed nurse assessed the resident for injury after he entered his room. At 5:00 p.m., observation of the exit gate from the smoking area, located at the south end of the property, revealed the gate was attached to a chain link fence in a grassy area that joined a paved road. b. Failure to monitor Resident #1 at night as planned A 3/18/2020 IDT risk management progress note revealed Resident #1 was put on 15-minute safety checks and when he was sleeping, staff were to sit in the hall to monitor the door to his room to ensure the resident did not get out of the facility. However, progress notes above dated 4/19 and 4/20/2020 (see above) read Resident #1 had been setting door alarms off by continued door seeking behavior throughout the night (4/19/ ) and wandering the halls, door seeking through the setting the door alarms off (4/20/ ). c. Failure to take steps to ensure other unsafe and/or unsanitary behaviors as planned (1) A 2/14/2020 IDT risk management progress note (see above) revealed the resident had a behavior of participating in poor eating etiquette during meal times by reach in other residents ' plates on 2/13/2020. This was first documented in nursing progress notes 11/26/19 and 11/27/19 (see above). However, while the 2/14/2020 IDT note read the resident was to receive meals prior to dining meal times to provide a calmer environment, this intervention was not care planned until 3/2/2020. (2) There was no evidence the facility developed and implemented effective interventions to address Resident #1 ' s urination and defecation in inappropriate locations, which progress notes revealed continued (see above). (3) There was no evidence the facility developed and implemented effective interventions to protect against Resident #1 placing metal objects in electrical outlets. Observations on 4/23/2020 at 12:30 p.m. revealed all electrical outlet sockets in the main dining room were not covered or plugged with any safety mechanisms. D. Record review 4/22/2020, after the facility was informed its failure to meet Resident #1 ' s need for supervision created a likelihood for serious adverse outcome if not corrected. Record review revealed the facility placed Resident #1 on one to one supervision (see abatement plan above) and updated his care plan to read, Resident placed on one to one for safety and care needs. Record review further revealed when receiving this level of supervision, the resident did not attempt to elope. -A 4/23/2020 nursing progress note revealed the resident was on one to one supervision and had no elopement attempts. -A 4/23/2020 a Wandering/Elopement Risk Assessment revealed the resident was a high risk for wandering with a score of 12. -A 4/24/2020 nursing progress note revealed the resident remained on one to one supervision and had no elopement attempts. -A 4/25/2020 nursing progress note revealed the resident continued on one to one supervision, was easily redirect able and had no elopement attempts. Other nursing progress notes on 4/25/2020 revealed the resident exhibited a witnessed [MEDICAL CONDITION] activity in his room at 8:15 a.m. that lasted approximately eight minutes. It indicated the resident hit the right side of his head during the [MEDICAL CONDITION] and was non-responsive. The resident was sent to the emergency room for further evaluation and treatment and returned to the facility at 3:15 p.m. with no new orders and was able to ambulate back into the facility with a steady gait. -A 4/26/2020 nursing progress note revealed the resident remained on one to one observation with no elopement attempts. -A 4/27/2020 nursing progress note revealed the resident remained on isolation precautions for COVID-19 and had one to one supervision around the clock. E. Staff interviews 1. CNA #1 and agency CNA #2 were interviewed

Based on observations, record review and interviews; the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, as evidenced by significant weight loss for one(#54) of three residents reviewed for nutrition of 26 sample residents. The facility failed to provide the appropriate diet; evaluate the effectiveness of current nutritional interventions; and initiate additional nutritional interventions which contributed to the significant weight loss and a delay in newly identified wound for Resident #54. Based on observations, the resident received regular foods that were not on her physician ordered mechanical soft diet both by the facility and the resident's family. The resident's current identified weight loss occurred on 4/11/19 and again on 4/30/19. The resident had been on med pass (supplement drink) since (YEAR) and protein liquid since (YEAR) with minimal intake per records and interviews. No new nutritional interventions were initiated or evaluated. Additionally, The most recent nutritional assessment was completed 1/24/17. There were no current nutritional assessments completed. The most recent quarterly nutrition note was completed on 2/2/19. The record review was void of any dietary notes from 9/25/18 through the most current note dated 4/29/19. The most current dietary note revealed a recommendation for med pass 30 milliliters (ml) per day which would have been a reduction in supplementation. The interdisciplinary (IDT) weight/skin meeting notes revealed a recommendation to increase med pass to four ounces four times a day (QID) on 4/3/19. This was not implemented. The same recommendation was documented on each additional IDT meeting note. Current supplemental intake was not evaluated for effectiveness. No other nutritional interventions were initiated. Findings include: I. Facility policy and procedure The Hydration and Nutrition policy, undated, provided by the director of nurses (DON) on 5/2/19 at 8:00 a.m. revealed, in part, The nutrition and hydration status of each resident is maintained as close to optimal level as possible . The appropriate food .is served to each resident . An ongoing assessment of ability to consume and assimilate food and fluid by resident is conducted by nursing personnel. Assessment includes: environmental and social considerations; ability of resident to chew, drink and swallow; weight loss . Consultation with dietary and rehabilitation personnel is performed on admission and during scheduled team conferences . Observation for the desired effect or adverse response is performed and documented in nurses' notes. The Weight Assessment and Intervention policy, revised (MONTH) (YEAR), provided by the DON on 5/2/19 at 8:00 a.m. revealed, in part, The dietitian will review residents' receiving weekly weights monthly to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant change has been met . The threshold for significant unplanned and undesired weight loss will be based on the following criteria: 1 month- 5% weight loss is significant; 3 months- 7.5% weight loss is significant; 6 months- 10% weight loss is significant . Assessment information shall be analyzed by the interdisciplinary team and conclusions shall be made regarding the: Resident's target weight range; approximate calorie, protein, and other nutrient needs compared with the resident's current intake. II. Resident #54 status Resident #54, age 60, was admitted on [DATE] with readmission on 4/16/19. According to the (MONTH) 2019 medication review report-computerized physician order [REDACTED]. The 4/14/19 minimum data set (MDS) assessment revealed the brief interview for mental status (BIMS) score was not completed. Documented was the residents height: 59 inches and weight: 99 pounds. Weight loss was marked as No. Her functional status for eating was total dependence. Skin conditions revealed: Does this resident have one or more unhealed pressure ulcers at stage 1 or higher? No was marked. -This would be inaccurate documentation as the resident developed his pressure ulcer on 3/12/19. A. Observations On 4/29/19 at 1:00 p.m., the resident was in the main living area nearest her room. Her mother was sitting next to her, assisting the resident with her lunch meal. The resident received cubes of meat, mashed potatoes, sliced cabbage (appearance of cole slaw), a roll and a cookie. Her mother said the food on her plate did not match the mechanical soft diet she was supposed to have received. The meat was too big and she received cabbage. When asked if she wanted another plate of food, she declined and said the resident probably would not eat much more anyway. Her mother was feeding her mashed potatoes. There was a milkshake on the tray next to her. -The menu extension for the mechanical soft diet displayed for the lunch meal included: ground braised pork tip, cheesy potatoes, multi-colored cauliflower, pureed white bread and snickerdoodle cookie. Review of the (MONTH) 2019 CPO revealed the order with a start date of 3/9/19: mechanical soft texture, regular/thin consistency, consuming small bites at slowed-rate of intake followed by a liquid wash. On 4/30/19 at 11:57 a.m., the resident was in the main living area nearest her room. Her mother was trying to feed her fried chicken strips with ketchup. The food was brought in from the outside. On 5/1/19 at 8:11 a.m. the resident was in the main dining room for breakfast meal. Staff was assisting her. The resident took a few bites. She ate some yogurt, pureed eggs and pureed meat. She drank some of the apple juice through a straw. On 5/1/19 at 12:00 p.m. the resident was observed in the living area nearest her room. Her mother was sitting next to her, assisting with her meal. She had a salad on the table and was feeding the resident some of the avocado. B. Record review The care plan, revised 5/17/17, revealed resident is at nutrition/hydration risk related to advanced [MEDICAL CONDITION] (MS), protein calorie malnutrition, [MEDICAL CONDITION], history of urinary tract infection [MEDICAL CONDITIONS], dysphagia, abnormal weight loss, dementia, neoplasm unspecified, [MEDICAL CONDITION], constipation, [MEDICAL CONDITION] (CKD) II. Interventions included: Mother wants small amounts of soft and easy to swallow food and offer chocolate milk with meals; encourage good meal intakes and offer substitutes for uneaten food; requires total assistance with meals; will receive a regular diet with mechanical soft texture and thin liquids; likes cold cereal and pancakes for breakfast; shake and ice cream offered at lunch and dinner; monitor and record all food and fluid intake. The care plan, last revised 5/19/17, revealed resident at risk for skin breakdown, skin tears, and bruising due to impaired mobility related to [MEDICAL CONDITION] (MS), incontinence, cystostomy in place, poor intakes, fragile skin and history of [MEDICAL CONDITION] and rashes, current pressure wounds. Review of the weights and vitals summary revealed the following: 1/10/19: 97.4 pounds 1/30/19: 100 pounds (3/12/19: New wound left gluteal fold, stage 2 open area) 3/14/19: 97 pounds 3/21/19: 97 pounds 4/4/19: 98.6 pounds 4/11/19: 93 pounds (5.6% weight loss x 1 week) 4/30/19: 90 pounds (7.2% significant weight loss x 1 month) Review of the most recent Dietary Nutritional Assessment, 1/24/17, revealed: Diet order: mechanical soft, regular, thin, fortified foods with intake 0-25%. On med pass 120 ml twice daily (BID), magic up or shakes with meals with intake 0-25%. Dining ability: total dependence. Oral function: coughing or choking during meals. Admission weight: 87 pounds. Current weight: 87 pounds. Usual weight: 90-100 pounds. Estimated nutritional needs: based on 30 calories/kilogram (kcal/kg): 1200-1440 kcal. Protein in grams (gms): 40-48 gms based on 1.2 gms/kg. Fluids: greater than 1500 ml. Percent intake required to meet estimated needs: 62%. -There were no additional dietary nutritional assessments completed since 1/2017. Review of the most recent Quarterly Nutrition note, 2/2/19, revealed: Height: 58 inches; weight: 100 pounds (1/30/19). Oral (PO) intake: 0-100%, typically poor to fair intake of meals. Supplement: 90ml med pass QID (600 kcal, 30 gms protein), protein supplement 15 ml PO BID mixed with cranberry juice (100 kcal/15 gms protein). Currently on regular mechanical soft/ thin liquid diet, tolerating well. Order for weekly weights active. She stays around 100#, no significant weight fluctuations x 6 months. Skin integrity intact at this time. She is currently on two supplements, med pass and protein supplement. Recommend: continue current diet and supplement regime. -This assessment was completed by the previous registered dietitian (RD)/dietary supervisor (DTS). Review of the (MONTH) 2019 MAR for med pass supplementation revealed intake mostly 0-30%. The resident consumed above 25% intake of med pass; 18 out of 112 times (16%). The resident refused med pass 43.7% times. The residents intake of protein supplement averaged 0-30 ml each time offered. Review of the (MONTH) 2019 CPO revealed: -2/28/18: 90 ml med pass QID for weight loss. -3/2/17: Active protein liquid add 15 ml mixed in 4 ounce (oz) of cranberry juice twice a day. The (MONTH) 2019 Medication Administration Record [REDACTED] -No changes in med pass since (YEAR) and no changes in protein liquid since (YEAR). Review of the (MONTH) 2019 MAR for med pass supplementation revealed intake 0-60% with mostly 0-25% taken. The resident consumed above 25% intake of med pass; nine out of 118 times (7.6%). The resident refused med pass 45.7% times. The residents intake of protein supplement averaged 0-60 ml each time offered. Review of the (MONTH) 2019 meal intake records revealed: -Intake was 0-25% for 20 out of 77 meals. (25.9%) -Intake was 26-50% for 29 out of 77 meals. (37.6%) -Intake was 51-75% for six out of 77 meals. (7.7%) -Intake was 76-100% for three out of 77 meals. (3.8%) -There was no documentation for 18 out of 77 meals. (23.3%) Review of the IDT team notes for weight/skin revealed: -3/8/19: Weight: 99 pounds (3/7/19). Supplement ordered #1: med pass 90 milliliters (ml) oral (PO) four times a day (QID). Accepted/not accepted: blank. Supplement ordered #2: Protein supplement 15 ml PO twice daily (BID) in cranberry juice. Accepted/not accepted: blank. The team documented the resident did not have a wound. Supplement acceptance was not evaluated. Recommendations included: increasing med pass to four ounces PO QID. Encourage PO intake of meals/supplements/fluids/snacks. Continue protein supplement and continue to monitor through nutrition at risk (NAR) team. -The previous registered dietitian (RD) was in attendance and this note was signed by the assistant director of nurses (ADON). Review of the 3/12/19 skin assessment- non-pressure ulcer, revealed the following: Initial evaluation was marked. Onset date: 3/12/19. Was skin/ulcer present on admission? No. Site: left gluteal fold; stage 2 open area. Review of the progress notes revealed the following: -3/21/19: Resident refused to drink med pass this morning. Review of the IDT team notes for weight/skin revealed: -3/26/19: Weight: 97 pounds (3/21/19). Supplement ordered #1: med pass 90 ml QID. Accepted/not accepted: blank. Supplement ordered #2: Protein supplement 15 ml PO BID in cranberry juice. Accepted/not accepted: blank. -The team documented the resident did not have a wound. Supplement acceptance was not evaluated. Recommendations included: increasing med pass to four ounces (120ml) PO QID. Encourage PO intake of meals/supplements/fluids/snacks. Continue protein supplement and continue to monitor through NAR team. The previous RD was in attendance and this note was signed by the ADON. -The recommendation to increase med pass to 120 ml was not done. Review of the (MONTH) 2019 MAR for med pass supplementation revealed intake 0-75% with mostly 0-50% taken. The resident consumed above 25% intake of med pass thirty-four out of 120 times (28.3%). Med pass was refused fifty out of 120 times (41.6%). The residents intake of protein supplement averaged 0-60 ml most of the time offered. She accepted 120 ml on 4/5/19. Review of the (MONTH) 2019 meal intake records revealed: -Intake was 0-25% for 29 out of 90 meals. (32%) -Intake was 26-50% for 12 out of 90 meals. (13%) -Intake was 51-75% for five out of 90 meals. (5.5%) -There was no documentation for 39 out of 90 meals. (43.3%) Review of the IDT team notes for weight/skin revealed: -4/3/19: Weight: 97 pounds (3/21/19); Usual body weight: mid to high 90s. Meal intake: 0-100%. Supplement ordered #1: med pass 90 ml PO QID. Accepted/not accepted: blank. Supplement ordered #2: Protein supplement 15 ml PO BID in cranberry juice. Accepted/not accepted: blank. -The team documented the resident did not have a wound. Supplement acceptance was not evaluated. -Recommendations included: increasing med pass to four ounces (120 ml) PO QID. Encourage PO intake of meals/supplements/fluids/snacks. Continue protein supplement and continue to monitor through NAR team. The previous RD was in attendance and this note was signed by the ADON. -The recommendation to increase med pass to 120 ml was not done. Review of the IDT team notes for weight/skin revealed: -4/8/19: Weight: 98.6 pounds (4/4/19). Meal intake: 0-100%. Supplement ordered #1: med pass 90 ml PO QID. Accepted/not accepted: blank. Supplement ordered #2: Protein supplement 15 ml PO BID in cranberry juice. Accepted/not accepted: blank. The team documented the resident did not have a wound. Supplement acceptance was not evaluated. Recommendations included: increasing med pass to four ounces (120 ml) PO QID. Encourage PO intake of meals/supplements/fluids/snacks. Continue protein supplement and continue to monitor through NAR team. The previous RD was in attendance and this note was signed by the ADON. -The recommendation to increase med pass to 120 ml was not done. Review of the weights and vitals summary revealed the resident weight was taken on 4/11/19: 93 pounds (5.6% weight loss x 1 week). Review of the IDT team notes for weight/skin revealed: -4/17/19: Weight: 93 pounds (4/18/19). Meal intake: 0-100%. Supplement ordered #1: med pass 90 ml PO QID. Accepted/not accepted: blank. Supplement ordered #2: Protein supplement 15 ml PO BID in cranberry juice. Accepted/not accepted: blank. The team documented the resident did not have a wound. Supplement acceptance was not evaluated. Recommendations included: increasing med pass to four ounces (120 ml) PO QID. Encourage PO intake of meals/supplements/fluids/snacks. Continue protein supplement and continue to monitor through NAR team. The current DTS was in attendance and this note was signed by the ADON. -The recommendation to increase med pass to 120 ml was not done. Review of the progress notes revealed the following: -4/22/19: Resident refused to drink protein supplement and refused med pass this shift. -4/23/19: Resident had poor appetite this shift, tolerated small amounts of med pass and water. Review of the IDT team notes for weight/skin revealed: -4/24/19: Weight: 93 pounds (4/18/19). Meal intake: 0-100%. Supplement ordered #1: med pass 90 ml PO QID. Accepted/not accepted: blank. Supplement ordered #2: Protein supplement 15 ml PO BID in cranberry juice. Accepted/not accepted: blank. The team documented the resident did not have a wound. Supplement acceptance was not evaluated. Recommendations included: increasing med pass to four ounces (120 ml) PO QID. Encourage PO intake of meals/supplements/fluids/snacks. Continue protein supplement and continue to monitor through NAR team. The current DTS was in attendance and this note was signed by the ADON. -The recommendation to increase med pass to 120 ml was not done. The above IDT meeting notes revealed there were no evaluations for intake/weight loss or changes in interventions. There was no acknowledgment of the open wound that developed in March. Review of the medical doctor (MD) progress notes, in pertinent part, revealed: -4/24/19: Reason for appointment: Left gluteal ulcer. Assessments: Pressure injury to skin; Pressure injury to left buttock, stage 3. Treatment: The patient does have a left gluteal ulcer, stage 3 now, being followed by in-house wound care. Currently, we do not have a wound care physician, we will need to appoint another, being managed by the assistant DON. Protein calorie-malnutrition-recheck labs. Follow- up dietary. Current history of present illness: The patient does have a left gluteal ulcer, noted to be stage 3 from wound care rounds. Review of the physician assistant (PA) progress notes, in pertinent part, revealed: -4/26/19: Hospital course: The patient also had an incidental finding of bilateral [MEDICAL CONDITION] nodules. The patient does have significant dysphagia, requiring mechanical soft diet only. Review of symptoms: Decreased appetite. Assessments: Pressure injury of skin; protein-calorie malnutrition. Treatment: Pressure injury- the patient does have sacral ulcer stage 2, in house wound care. Protein calorie-malnutrition- continue to monitor. The patient is on mechanical soft diet. -4/29/19: Hospital course: The patient does have significant dysphagia, requiring mechanical soft diet only. Review of symptoms: Decreased appetite. Assessments: Pressure injury of skin; protein-calorie malnutrition. Treatment: Pressure injury- the patient does have sacral ulcer stage 2, in house wound care. Protein calorie-malnutrition- continue to monitor. The patient is on mechanical soft diet. The PA documentation was inconsistent with the MD documentation. Review of the dietary notes revealed: 4/29/19: RD review for weight. Value: 93 pounds. Prescribed diet and supplement can meet needs with adequate intake. Med pass 2.0 30 ml per day may be beneficial for additional caloric intake. Will discuss with DON. The resident had been receiving 90 ml med pass QID since 2/28/18 as listed above. No other dietary notes since 9/25/18. This note was documented during survey. Review of the (MONTH) 2019 CPO, in part, revealed: -5/1/19 start date: Magic cup in the evening for weight stability -5/2/19 start date: Prostat one time a day 30 grams (gms) daily for wound healing. -5/2/19: start date: Multivitamin (MVI) with minerals. Give one tablet by mouth one time a day for supplement. The above supplements were ordered the week of survey. C. Interviews Registered nurse (RN) #3 was interviewed on 5/1/19 at 9:45 a.m.She said this resident used to eat 80-90% at meals. Intake was currently 20-30% of solid foods. She said she tried to give her 120 ml fluids (regular) at each med pass. She said Resident #54 had been declining over the past three weeks. She said se had newly diagnosed cancer. She said with the med pass; she will not take. They pushed regular fluids and juice. She said, she might have been refusing the med pass because it was similar to the milkshake the residents mother was bringing in every day. She usually took about one to two sips of the milkshake. The staff had tried another supplement (name of supplement) before the med pass. She had some previous weight fluctuations. RN #3 said she did not attend the weight/skin meetings. She said she thought management attended the meetings. She said she thought constant persistence would help. The residents mother preferred the resident to have apple juice. The resident liked cranberry juice. They had tried the pureed diet and her mom had sent it back. Her mom brought in regular foods from (name of fast food chain). She said, they had educated her about the proper food consistency. The resident ate better when her mother was not around. She said the staff could take their time with her so she could clear her food in-between meals. Certified nurse aide (CNA) #3 was interviewed on 5/1/19 at 9:50 a.m. She said this resident did not eat well at her meals. She needed coaxing. She did well with her fluids. During assistance, they would have to stop and reapproach. She said the resident was on pureed this morning. They needed to find new foods that she would eat. She liked the apple juice, sometimes milk and hot tea. They had to offer her different things to see if she would take it. The resident had been declining over the past month. She said her mom always brought in (name of fast food chain). The resident always seemed nervous around her mother. She would rub her face and appeared uncomfortable. Her demeanor changed when her mom was there. They tried to feed her high calorie things. She said she thought they needed to brainstorm and get with the RD. The resident would get a snack at 3:00 p.m. and then lie down after that. The RD was interviewed on 5/1/19 at 12:11 p.m. She said she had been coming to the facility for about two years. They had hired an RD/DTS in (MONTH) and she would document on the residents. She was no longer at the facility. The RD said she had looked at some residents with weight loss when she came in on Monday. She got a list of the residents who needed to be seen. She said the ADON had been helping with the weight loss/skin documentation. She said the previous RD/DTS was here about 60 hours per week. The RD said that last summer, they had gotten this resident to come into the dining room without her mom and she did better. She said she had recently noted this resident had weight loss and was going to see about supplementation. The new DTS had been at the facility for about a month. The MD was interviewed on 5/1/19 at 12:35 p.m. She was talking with the resident and her mom. She said this resident had protein calorie-malnutrition and a wound that was reported as a stage 3 last week. The ADON had reported that the wound was getting worse. She said this resident's oral intake was subjective and that her mom tended to try and force-feed the resident. The ADON was interviewed on 5/1/19 at 1:53 p.m. He said the RD was reviewing residents over the past two days. The current RD covered several buildings. The ADON said he had been the one documenting on the weight loss/skin. The corporate consultant (CC) was interviewed on 5/2/19 at 11:14 a.m. She said she was wound certified. She said, the facility was going back and forth about whether or not it was a pressure ulcer for this resident. She said she looked at it and it was obviously a pressure ulcer. She said she asked for multivitamin with minerals and protein powder. She said she did not feel like the resident had enough protein. She said all of the other preventative measures were in place for her wound.

Based on observations, interview and record review, the facility failed to ensure one (#44) out of one sample residents, who had a [DIAGNOSES REDACTED]. Resident #44 was admitted to the facility with a known history as a tortured prisoner of the Vietnam war and with [DIAGNOSES REDACTED]. The facility failed to provide Resident #44 with the assessments and individualized care planned interventions, based on such assessments, orders, and training on [MEDICAL CONDITION], necessary to address his distress, prevent physical harm, and promote his highest practicable level of mental and psychosocial well-being. Resident interview revealed on-going signs and symptoms of emotional distress, including night terrors/nightmares, blackouts with falls, [MEDICAL CONDITION], self-isolation, depression and fear. Findings include: I. Resident #44 A. Resident status Resident #44, age 69, was admitted on [DATE]. According to the (MONTH) 2019 computerized physician orders [REDACTED]. In an interview on 4/29/19 at 3:48 p.m., Resident #44 said he was a wartime veteran, a prisoner of war and had been tortured, causing his [MEDICAL CONDITION]. According to the minimum data set ((MDS) dated [DATE], the resident had mild cognitive delays and scored a 12 out of 15 on his brief mental status exam. The resident required extensive assistance with activities of daily living and utilized a wheelchair, walker and a cane, depending on the activity and how he felt for the day. The resident's care plan dated 12/27/18 identified the resident as having [MEDICAL CONDITION], and read that staff were to document side effects - anti-depressant, change in behavior, mood, cognition, gait changes, balance and movement problems, anxiety [MEDICAL CONDITION], dizziness and [MEDICAL CONDITION]. It also read the resident was at high risk to fall. B. Resident #44's report of, and observed signs and symptoms of, emotional distress 1. Resident #44 was interviewed on 4/29/19 at 3:48 p.m. and 3:51 p.m. and on 4/30/19 at 3:25 p.m. The resident said he was traumatized by what happened to him during the war. He described dreams, night terrors, of being tortured again and having his toes removed just like when he was a prisoner of war. He said he awakens drenched in sweat and scared. Resident #44 said the dreams were at times so real and so bad that there was no way for anyone to understand. He said, other times, he could not sleep and sometimes this went on for days. He said he also experiences [MEDICAL CONDITION] blackouts, which he described as everything being out of focus, in a frightened state, and without the ability to think or hear. He said twice the blackouts had resulted in falls to the ground. After the blackout, he said he wakes up in his bed and he does not know how he got there. The resident said he does not always talk about the blackouts because he did not believe someone who has not seen war or tortured after being captured could comprehend what he was going through or the extent of his suffering; he said someone who learned of [MEDICAL CONDITION] from a book would not understand. Resident #44 said he copes by spending his time out on the patio smoking alone, sometimes late into the night. Resident #44 said his [MEDICAL CONDITION] blackouts and his night terrors have been reported to staff. He said he had spent time talking with the activities director (AD), as she listened. Resident #44 said at times he just cried and held the AD's hand as he described what had happened in Vietnam and his night terrors, but there was a lot she could never understand. The resident said he did not like to burden staff or complain, so he only talks to staff when it is really bad. Resident #44 said he does not want more pills; he is tired of being medicated and would like to find a resolution to the problem. The resident stated he would be open to a counselor who had similar experiences. He said this had not been offered as an option. He explained he did not want to talk about his situation with people who did not understand, and he did not think a young person could understand what he had had been through (see resident interview above). He said he had talked in groups the social services was offering before, but their conversations did not relate to his experience. He wanted to talk with someone one to one (1:1). 2. Observations of Resident #44 daily during survey (4/28 - 5/2/19), self-isolating. Observations revealed Resident #44 largely remained in his room with curtains closed when he was not smoking. He appeared anxious and weary, jumpy to sudden movements and nervous about crowds in areas a typical person would say was semi-populated. The resident chose to eat lunch on 4/30/19 after 70 % of the residents had left the dining room; even then, he chose to sit away from everyone else. He did not attend activities, stating it is too much, too many people and too many noises. C. Record review and interviews confirmed Resident #44's signs and symptoms of distress - [MEDICAL CONDITION] blackouts with falls, night terrors, and self-isolation. 1. Record review A physician progress notes [REDACTED]. It will awaken him from a deep sleep. The resident said he just feels better curled up in bed and not sleeping. A care plan note dated 1/7/19 read the resident had fallen during an episode of [MEDICAL CONDITION]. A progress note dated 3/7/19 read the resident had fallen out of bed due to a bad dream/flashback. A physician progress notes [REDACTED]. A progress note dated 4/10/19 read the resident had fallen in the activity room. Registered nurse (RN) #2 said the resident had reported an episode of [MEDICAL CONDITION]. Another note on 4/11/19 read the resident's night terrors were being monitored. A psychiatric evaluation dated 4/16/19 read the resident was seen for an increase in antidepressant medication. The resident reported ongoing problems with depressed mood, low energy, and occasional anxiety without identified triggers. The resident reported occasional night terrors and avoidance of situations with large crowds. The resident denied having any recent flashbacks or hypersensitivity due to [MEDICAL CONDITION]. The evaluation stated the resident kept to himself with limited social interactions. -The evaluation showed the resident was on current psychiatric medication [MEDICATION NAME] for night terrors. The mental status examination revealed the resident's mood is described as dysphoric (state of unease). The [DIAGNOSES REDACTED]. -The evaluation included care plan recommendations, including depression-stress management, conversations about glass half full vs glass half empty with the goal to increase positive coping strategies and increased activities in structured activities (non-pharmacologic interventions). -The treatment plan included labs, the antidepressant [MEDICATION NAME] in the a.m., [MEDICATION NAME] in p.m. (stable at current dose or needs more time to see beneficial effects) A progress note by social services dated 4/16/19 read the resident was encouraged to express feelings of anger, behaviors of [MEDICAL CONDITION] appropriately and prn as needed. Social services offered additional therapeutic services at this time, but the resident declined (see resident explanation above). 2. Staff interviews Registered nurse (RN) #4 was interviewed on 4/30/19 at 11:00 a.m. and 5/1/19 at 9:44 a.m. She said the resident will have prisoner of war flash backs then black out and fall. She also said the resident sleeps 4-5 hours a night and has reported going for days without sleeping. She said this was a result of his [MEDICAL CONDITION]. She further confirmed the resident had fallen out of bed on 3/7/19 due to a [MEDICAL CONDITION] episode and they believed he had torn his rotator cuff as a result. She said the resident fell again on 4/2/19 at 3:42 p.m. and this, too, was noted as a [MEDICAL CONDITION] episode. In that fall, the resident had sustained scratches to the left hips and left arm. The activities director (AD) was interviewed on 5/1/19 at 3:58 p.m. She stated the resident had spoken with her in the past about nightmares and how they keep him up at night. She also confirmed the resident spoke of his [MEDICAL CONDITION] and experiences in the war. Certified nurse aide (CNA) #2 was interviewed on 5/1/19 10:37 a.m. CNA #2 said witnessed the resident's fall in the activity room [ROOM NUMBER]/10/19 and said the resident later told her he had felt faint, grew weak, and passed out. II. Facility failure to provide Resident #44 with the assessments and individualized care planned interventions based on such assessments, orders, and training on [MEDICAL CONDITION], necessary to address his distress, prevent physical harm, and promote his highest practicable level of mental and psychosocial well-being. A. Record review See care plans above. The resident had care plans for [MEDICAL CONDITION], falls, and side effects of anti-depressants. None of the care plans included specific assessment information about Resident #44's [MEDICAL CONDITION] signs and symptoms, triggers for his [MEDICAL CONDITION] blackouts and falls, the character of his flashbacks and night terrors, his [MEDICAL CONDITION], and self-isolation. See care plans above. None of the care plans prior to survey included individualized interventions to address Resident #44's [MEDICAL CONDITION], based on comprehensive assessment about his signs and symptoms of emotional distress and understanding of [MEDICAL CONDITION]. During survey, on 4/30/19, a care plan was developed which read Resident #44 was dependent on staff for meeting emotional, intellectual, physical, and social needs. The resident was identified as needing staff assistance in regards to depression behaviors as evidenced by verbalized sadness, self-isolation, unprovoked verbally aggressive behaviors, profanity, and withdrawal. However: -There was no evidence from the care plan the facility had developed and implemented a process to ensure how staff was to assist the resident in meeting his emotional, intellectual, physical and social needs, and what person-centered approaches would be implemented to support the resident. -The care plan revealed no consideration of individual counseling. -The care plan failed to include any specific non-pharmacological interventions, including those included in the psychiatric evaluation (see above) to increase positive coping strategies and increased activities. -The care plan failed to include an order, initiated 2/19 to current that read the resident should be monitored daily for psychiatric evaluation for stabilization of depressed mood, and review of the resident's treatment administration record (TAR) revealed no evidence this monitoring was being done. B. Staff interviews Staff interviews confirmed the facility's failure to conduct the assessments necessary to develop an individualized care plan to address Resident #44's signs and symptoms of emotional distress as well as monitor the resident for stabilization of depressed mood. Moreover, none of the staff reported training in [MEDICAL CONDITION], including symptom identification and appropriate intervention. 1. Social Services Director (SSD) The SSD was interviewed dated 4/30/19 at 10:00 a.m. and again at 11:45 a.m. She said Resident #44's [MEDICAL CONDITION] symptoms related to falling were not reported to her. She also said she did not know the resident was not sleeping, sometimes for days, due to night terror episodes. She confirmed there were no non-pharmacological interventions, triggers or monitoring in place to support the resident and address his signs and symptoms of emotional distress. The SSD also confirmed she did not know what symptoms of [MEDICAL CONDITION] looked like and confirmed they had not been identified on the resident's care plan. After reviewing the resident's record, she confirmed the findings in the 4/16/19 psychiatric evaluation on 4/16/19. The SSD also confirmed in a progress note dated 4/16/19 that the resident was encouraged to express feelings of anger, behaviors of [MEDICAL CONDITION] appropriately and prn as needed and declined additional therapeutic services. But see resident interview above regarding a willingness to participate in 1:1 counseling; the SSD did not indicate and the record did not reveal the resident had been re-approached about additional services or asked what services would be appropriate for him. 2. Direct care staff Registered nurse (RN) #4 was interviewed on 4/30/19 11:00 a.m. and again at 2:27 p.m. See interview above; the RN confirmed the resident slept 4-5 hours a night as a result of [MEDICAL CONDITION]. RN #4 also confirmed the resident had reported going for days without sleeping. The RN said it was hard to determine how much sleep the resident needed and if the missing sleep was due to pain or symptoms of [MEDICAL CONDITION]. The RN confirmed the resident had fallen out of bed on 3/7/19 due to a [MEDICAL CONDITION] episode and it was believed he had torn his rotator cuff. The RN said the resident fell on [DATE] at 3:42 p.m. and this, too, was noted as a [MEDICAL CONDITION] episode. The resident had sustained scratches to the left hip and left arm. The RN said the resident's falls were addressed in the care plan, but not in relation to a [MEDICAL CONDITION] trigger. It was also confirmed the resident will isolate at times and she said this was not monitored or recorded in documentation. She also confirmed the resident's care plan did not identify triggers of [MEDICAL CONDITION], interventions or monitoring. She confirmed a doctor's order dated 2/19 through the present showed a psychiatry evaluation for stabilization of depressed mood was to be done daily and monitored. RN #4 said this had never been done and she was unsure what this would look like. The RN said there was no follow up with the doctor to clarify this order. 3. RN #2 was interviewed 4/30/19 4:48 p.m. RN #2 confirmed orders on the treatment administration records (TAR) read the resident should be monitored daily for psychiatric evaluation for stabilization of depressed mood and confirmed there was no evidence this order was being implemented. The RN confirmed the care plan did not reflect the order. The RN said she has had no training in regard to this order. 4. The assistant director of nursing (ADON) was interviewed on 5/01/19 at 1:57 p.m. and on 5/2/19 at 10:49 a.m. The ADON said he worked a lot of nights with Resident #44. He agreed the facility did not identify triggers, interventions, and tracking related to the resident's sleeping pattern or [MEDICAL CONDITION] episodes in the care plan. The ADON said there is no staff training specifically for [MEDICAL CONDITION]. The ADON confirmed a physician's orders [REDACTED]. The ADON stated they were going to request to have it discontinued as he did not know what the physician was asking the staff to do. 5. The activities director (AD) was interviewed on 5/01/19 3:58 p.m. See interview above; the AD stated the resident had spoken with her in the past about nightmares and how they keep him up at night. She also confirmed the resident spoke of his [MEDICAL CONDITION] and experiences in the war. The AD said this was discussed with team mates at the morning meetings and different interventions were mentioned to support the resident; however, they had not been put in place. The AD said she did not have [MEDICAL CONDITION] training. 6. The director of nursing (DON), SSD, and the corporate consultant (CC) #2 were interviewed on 5/1/19 4:16 p.m. The DON was interviewed again on 5/2/19 at 9:47 a.m. and the DON and CC #2 were interviewed again on 5/2/19 at 10:26 a.m. On 5/1/19, the staff confirmed the facility did not have [MEDICAL CONDITION] training in place but said they offer client specific training. CC #2 gave the example, if someone had night terrors, they would offer that training in relation to the resident. (See resident interview and record review above, indicating night terrors were included in the resident's signs and symptoms of emotional distress.) On 5/2/19, the DON said she was aware the resident had episodes of [MEDICAL CONDITION]. She said she had never seen an episode of [MEDICAL CONDITION] and could not comment on what that would look like. She said the triggers had not been identified and most occurrences seemed to be episodes of night terrors. She said the nursing staff would talk to the resident and she was aware that he would go out to the patio to smoke in the middle of the night. The DON also said she was aware of the sleeping patterns of the resident were not consistent and they were going to start tracking them. The DON also acknowledged the resident did not have non-pharmaceutical interventions identified on the care plan. On 5/2/19, the DON and CC #2 confirmed on 3/7/19 the resident had fallen out of bed and jammed his arm and neck. It was also confirmed the resident had injured his left elbow, knee and his left side and it was believed he had torn his rotator cuff. The interview also confirmed the fall related to [MEDICAL CONDITION] symptoms. The DON confirmed on 4/7/19 in the activity room, the resident had injured his left side with an upper hip abrasion. There was no follow up assessment to either fall relating to the [MEDICAL CONDITION]. 7. CNA #2 said the resident had fallen in the activity room about a week ago due to a [MEDICAL CONDITION] blackout. The resident had falls related to having these episodes. 8. CNA #1 was interviewed on 5/2/19 9:24 a.m. the CNA #1 said she witnessed the resident's fall on 4/10/19 and that she assisted the resident after the fall. The CNA said the resident will become very distant and will isolate himself before a [MEDICAL CONDITION] episode. The resident told the CNA he blackouts and does not remember what happened during the episode. The CNA said there is no client specific training for his [MEDICAL CONDITION] or depression. C. Facility follow-up during survey The facility provided an email showing on 4/30/19 at 4:00 p.m., the SSD had contacted Veterans Association for psychological services with resident preferences for care. The SSD said she talked to the resident and informed him she was reaching out for services. The resident agreed to these services.

Based on observations, interviews, and record reviews, the facility failed to provide five residents (#1, #2, #3, #10 and #11) all of whom were at risk for pressure ulcers, the care and services necessary to prevent the formation of pressure ulcers and the worsening of existing pressure ulcers. Specifically, the facility failed to: -Assess the risk for pressure ulcers for resident #2, a resident with a history of a stage III pressure area to the sacrum prior to admission. -Identify, care plan and implement interventions to prevent the formation of pressure ulcers for residents #1, #2, #3, #10, and #11. -Provide thorough initial assessment for residents #1, #2, #3, #10 and #11 upon identification of newly formed pressure ulcers, as well as thorough, ongoing assessment of pressure ulcers for residents #1, #2, #3, #10, and #11. -Provide timely physician and family notification of newly identified pressure ulcers for resident #2. -Provide ordered treatments to heal and prevent the worsening of newly formed pressure ulcers for residents #1 and #2. -Consistently implement interventions to prevent the formation of pressure ulcers for residents #1, #2, #3, #10, and #11. -Inform outside providers of care for resident #1 of the resident's pressure areas so that they could take precautions related to the resident's pressure areas. The facility's failures resulted in the formation of multiple and/or advanced stage pressure ulcers for residents #1, #2, #3 and #10. Residents #1 and #2 required hospitalization and and resident #2 required surgical interventions to address the pressure ulcers developed at the facility. The facility's failures related to pressure ulcer prevention and care presented a situation of immediate jeopardy that resulted in actual harm. The findings include: I. Immediate Jeopardy A. Findings Triggering Immediate Jeopardy Observations, records reviews and interviews with staff, health professionals, and family members demonstrated that the facility did not have an effective system in place prevent formation of pressure ulcers for at-risk residents. Staff did not consistently assess for risk of pressure ulcer development and did not implement effective prevention strategies to prevent the formation of pressure ulcers for at-risk residents. Staff did not effectively communicate the formation; timely notify physician; treat; or provide on-going assessment of pressure areas that formed on residents in the facility. The facility's failures resulted in development and worsening of pressure ulcers for residents #1, #2, #3, #10 and #11. B. Imposition of Immediate Jeopardy On 2/18/16 at 3:18 p.m., the nursing home administrator (NHA), regional vice president of operations (RVP), and corporate nurse consultant (CNC) were informed by the Colorado Department of Public Health and Environment (CDPHE) that the facility's failures to prevent the formation of avoidable, advance stage pressure ulcers, infection of pressure ulcers, and the formation of multiple pressure ulcers created a situation of immediate jeopardy for serious resident harm. B. Facility Response and Removal of Immediate Jeopardy On 2/19/16 at 1:26 p.m., the facility submitted the following plan (draft #6) to remove the immediate jeopardy. The plan stated: 2/19/16 This is the facilities (sic) plan of action for the immediate jeopardy that was cited for F-314 Pressure Ulcers on 2/18/16 at 3:18pm: 1. All current dependent residents residing at Castle Rock Care Center were assessed by the director of nursing for wounds on 2/18/16. All current independent residents with known wounds were assessed by the director of nursing on 2/18/16. 2. Skin assessments will be conducted on admission, when new skin issues are identified, and weekly by a registered nurse. All wound assessments will include measurements, staging, and documentation related to the clinical aspects of the wound. The assessment will be documented in the clinical record of the resident. 3. Licensed nursing staff will be in-serviced on incident reporting related to identification of new pressure areas. Nurses will be in serviced on immediate implementation of wound treatment and intervention. This will be completed by a registered nurse supervisor within the staff members (sic) next scheduled shift. 4. The director of nursing will review pressure ulcer documentation including physician orders, measurements, staging and incident reports daily and failure to follow protocols by nursing staff will result in additional education and disciplinary action of exceptions identified. 5. The director of nursing will be notified daily of any changes in wounds or treatments. This will be reviewed by the IDT (interdisciplinary team) in the morning meeting. 6. The director of nursing will review high risk residents at least weekly and with identified skin changes, PAR levels (minimum amount on hand), Braden scores and inventory of all supplies for prevention and treatment of [REDACTED]. PAR levels will be established and maintained by the director of nursing. Preventative wound supply inventory will be reviewed weekly by the director of nursing. Physician specific wound supplies will be ordered by the director of nursing. 7. The facility will follow the change of condition policy for all residents which shall include notification to the responsible party, physician, and any orders will be documented in the resident's clinical record. 8. Licensed nurse will verify and document in the resident's clinical record every shift that air mattresses are functional and set to manufactures (sic) guidelines. On 2/19/16 at 3:07 p.m., the NHA and the RVP were notified that the immediate jeopardy had been removed. However, based on observations, interviews and record review the deficient practice remained at an H actual harm at a pattern level. II. Resident Failures Observations, record review and interviews revealed extensive and repeated failures by staff to implement measures designed to prevent the development of pressure ulcers and to promote healing. A. Resident #2 1. Resident #2, age below 55, was admitted to the facility on [DATE] from a rehabilitation hospital. The face sheet showed the resident's [DIAGNOSES REDACTED]. Information provided by the rehabilitation hospital to the facility demonstrated the resident had history of advance stage wound to the sacrum (stage III). Additionally, the resident was known to have no movement of the lower extremities and would thus require assistance with positioning to maintain skin integrity. The 11/16/15 discharge documentation from the rehabilitation hospital stated the resident had a stage I pressure area to the sacrum at the time of discharge to the facility. Per resident #2's record, resident #2 was discharged from the facility on 1/3/16 at 12:00 p.m. and admitted to the hospital for evaluation and treatment of [REDACTED]. The hospital history and physical on 1/3/16 documented a large decubitus ulcer with necrotic skin breakdown of the sacral area, as well as skin breakdown on both heels. The 1/4/16 note read the resident had [MEDICAL CONDITION] with a likely source of multiple decubitus ulcers. 2. Resident Status on Admission a. Cognitive, Behavioral and Functional Status The 11/23/15 admission minimum data set (MDS) comprehensive assessment revealed: - The resident had moderate cognitive impairment as evidenced by a brief interview for mental status score of 12 of 15. -The resident did not present with behavioral symptoms impacting self or others and did not exhibit signs and symptoms [MEDICAL CONDITION] or [MEDICAL CONDITION]. The resident did not exhibit rejection of cares. -The resident required extensive assistance from two or more staff for bed mobility, transfers, dressing, and toilet use. Extensive assistance from one staff was required for locomotion on and off the unit and personal hygiene. -The resident was independent with eating and was totally dependent on two staff for bathing. -The resident had a urinary catheter and was always incontinent of bowel. -The resident was not receiving any therapy or restorative nursing services. b. Skin Status The 11/16/15 facility admission nursing assessment revealed the resident had a stage II pressure ulcer to the sacrum. The 11/23/15 MDS (see above) also documented a stage II pressure ulcer on admission as well as no other pressure areas. 3. Failures on Admission in Pressure Ulcer Prevention and Management Review of the resident's 11/16/15 admission nursing assessment, documenting a stage II pressure ulcer to the sacrum, included no measurements, wound bed description, description of wound edges, surrounding tissue, drainage or odor. Review of the resident's record revealed the facility did not assess the resident's risk for skin breakdown using a standardized nursing tool for assessing the risk of skin breakdown, although the facility's Skin Assessment/Skin Check policy required such an assessment on admission, and the facility's electronic assessment tools included the ability to complete a Braden scale to identify risk of skin breakdown. Review of the 11/2015 treatment administration record (TAR) and 11/2015 computerized physician orders [REDACTED]. Review of the resident's record did not reveal an interim/acute/temporary plan for care for managing the resident's stage II to the sacrum despite his history of pressure ulcers, his immobility, and his incontinence. A care plan addressing the resident's risk for skin breakdown due to incontinence and decreased mobility due to [MEDICAL CONDITION] was dated 12/10/15, almost three weeks after the resident's admission. Review of the resident's 11/23/15 MDS documented the resident had pressure relieving devices for bed and chair; however, the plan documented he was not on a turning/repositioning program and on 2/17/16 at 9:40 a.m., licensed practical nurse (LPN #4), familiar with the resident during his stay at the facility, stated the resident was placed on a regular mattress on admission. Interview with the interim director of nursing (IDON) on 2/23/16 at 4:45 p.m., confirmed the above findings. -The IDON acknowledged the resident was not assessed for risk of skin breakdown on admission to the facility. Per the IDON, staff should complete the Braden scale assessment for all new admissions. -The IDON acknowledged the 11/16/15 admission assessment showed the resident had a stage II to the sacrum. The IDON stated the assessment did not include measurements, descriptions of the wound bed, edges, surrounding tissue, drainage, odor or other pertinent information germane to a wound assessment. -The IDON reviewed the physician orders [REDACTED]. The IDON stated the resident was not receiving any treatments for the stage II pressure area in 11/2016. -The IDON stated she was unable to locate a plan of care indicating the resident had an existing pressure area to the sacrum. 4. Failures after Admission in Pressure Ulcer Prevention and Management a. Family Interview - Significant decline in resident's skin status, lack of timely prevention measures and of family notification of change in the resident's condition. On 2/16/16 at 12:36 p.m., an interview with a family member, a professional nurse in a hospital setting who regularly visited the resident in the facility and who was involved with the resident's care, revealed she went to see the resident weekly at the facility and called frequently to check on the resident's well being. She said she learned the resident had a pressure ulcer on his sacrum during one of the check-in calls she made to the facility about the week before Christmas and approximately two weeks before he was discharged to the hospital on [DATE]. The family member stated the nurse would only say the resident had a wound and it was being treated with medi-honey. The nurse was unable to provide information on the staging of the wound or when it had formed. The family member stated when she visited the resident on 12/19/15 with another family member, the resident was lying in bed on a regular mattress. The resident was odorous from bathing refusals. The family member denied seeing the resident with boots or pillows for offloading pressure on the heels during the 12/19/15 visit. According to the family member, the resident was placed on an air mattress closer to Christmas. The family member stated she went to see the resident on 1/3/16 and was upset to see the resident's condition; she said the resident was ill and had been vomiting. She said she was present for the sacral dressing change and the wound, the size of both her fists held side by side, was covered with thick, black, smooth eschar. The family member said this huge wound developed at the facility. The family member stated a nurse at the hospital told her the pressure wound on the sacrum was all the way down to the bone. The wound was infected and the resident required two kinds of powerful antibiotics to treat the infection. The family member stated the resident also had deep pressure ulcers on both heels and a pressure area to the left knee when he was admitted to the hospital on [DATE]. According to the family member, the heel and knee wounds developed in the facility, too. The family member stated the consequences for the resident's pressure ulcers at the facility were serious. The resident required surgical debridement of the wound, removal of coccyx bone due to infection, bursectomy, placement of a wound vac, diverting [MEDICAL CONDITION], placement of feeding tube for wound healing; and a muscle flap repair to the sacral/coccyx area. The family member stated the facility did not keep her informed of the resident's status, including, in addition to his worsening pressure ulcers, his depression (cross refer to F319 for details) and his increasing refusals with cares which she thought may have contributed to the formation and worsening of the resident's pressure ulcers. b. Record Review - Significant decline in the resident's status (physical status - worsening of existing pressure ulcer and development of new ulcers; mental status - withdrawal, care refusals, decline in intake). Record review revealed the facility failed to comprehensively consider, evaluate and address the resident's decline in physical and mental status. A review of the resident's clinical record revealed the facility did not conduct a complete assessment of the resident's sacral or heel pressure wounds. The facility did not inform the resident's primary physician or family of the worsening status of the resident's pressure ulcers. The facility delayed implementing pressure offloading strategies until after the resident developed pressure ulcers. The facility delayed and inconsistently executed the implementation of wound treatments. The facility failed to consider the effect of the resident's declining mental status on the resident's resistance to cares and nutritional decline. (1) On 11/17/15 at 8:04 p.m., a nurse's note stated in pertinent part, Res (resident) cont (continues) to have a flat affect. Very forgetful. Unable to remember why he is here. Repeats same questions over and over. Pt (patient) asks Why am I here? How did I get here, What is your name? and How long he will be here and when can he leave? Due to the TBI ([MEDICAL CONDITION]), pt is unable to make appropriate decisions on his own. Res needs reminders to offload pressure to his bottom while in wheel chair. This nurse setting alarm to help remind the pt. However, even as the alarm goes off, he does not remember why the alarm was set. Requires constant cueing. When pt in is bed staff must turn pt every 2 hrs (hours) because he is not cognitive enough to turn himself. He forgets that he is eating and needs reminders to cont(inue) feeding himself .Small area to coccyx from previous breakdown. -Failure: The coccyx wound was not measured or described in any additional detail. No care plan to address the resident's skin breakdown and need for constant cueing to reposition was in place. (2) On 11/21/15 weekly skin assessment stated, pts (patients) skin warm, pink, CDI (clear dry intact). Pt with bruising to bilateral heels from previous wounds that have healed. No open areas. Redness to coccyx, no open wounds. -Failure: The body map locating the area of redness on the coccyx was not identified on the assessment. w No care plan to address the resident's skin breakdown and need for constant cueing to reposition was in place. (3) In pertinent part, the 11/28/15 the weekly skin assessment stated, Skin WDI (warm dry intact). No open areas or sores. Res has a small tear to the head of his penis from the Foley catheter .Cont. to monitor. -Failure: The body map on the assessment was not completed and no skin assessment was completed between 11/29/15 and 12/11/15. A care plan identifying the resident's risk for skin breakdown was opened 12/10/15; however, the care plan failed to note the resident's history of pressure ulcers, or to include information that the resident was unable to turn himself and the need for constant cueing and staff support every two hours to turn and reposition. (4) A 12/3/15 physician follow-up note showed the resident did not have skin breakdown at that time. No behavioral issues were noted. The physician did note the resident seemed very depressed. (5) The 12/12/15 skin assessment read in pertinent part, Skin warm, and dry, blister noted to R (right) heel, elevated foot to relieve pressure. -Failure: The body locating the blister was not completed. There was no measurement or further description of the right heel blister. There was no evidence the physician was notified of the heel blister and no treatment order was found in the telephone orders or on the TAR for the heel blister. (6) On 12/15/15 at 11:43 p.m., a nurse's note read the resident's Coccyx reddened and area not blanchable. The note stated the area was cleansed with wound cleanser, skin prep applied, and Optiform applied. The resident was turned onto right side and the certified nurse aides (CNAs) were instructed to turn the resident every two hours. -Failure: The note did not state that the physician was notified of the pressure area to the coccyx. No telephone order for the coccyx treatment listed above was found in the clinical record. The coccyx treatment listed above was also not reflected on the TAR. A nutritional care plan was opened 12/16/15; however, it did not address the resident's nutritional needs related to his existing pressure ulcers on his coccyx and right heel. (7) On 12/17/15, the resident's skin was assessed by the facility wound physician who visited weekly on Thursdays. The initial wound physician note showed the resident had three wounds to his sacrum. -Wound #1 to the medial sacral was described as necrotic tissue (unstageable) pressure ulcer. The wound measured 5cm length x 2.5 cm width x 0.5 cm depth with an area of 12.5 sq cm and a volume of 6.25 cubic cm. The wound bed was 26-50% black eschar. The periwound skin was normal for texture, moisture and color. -Wound #2 to the right sacral was described as a suspected deep tissue injury (DTI) that measured 2.5 cm length x 9 cm width with an area of 22.5 sq cm. The wound bed was 76-100% [MEDICATION NAME]. The periwound skin was normal for texture, moisture and color. -Wound #3 to the left sacral was described as a suspected deep tissue injury that measured 4cm length x 3cm width with an area of 12 sq cm. The wound bed was 76-100% [MEDICATION NAME]. The periwound skin was normal for texture, moisture and color. -The note stated the resident was recently found to have a sacral PU (pressure ulcer). He has several distinct wounds including two DTIs and one unstageable (but at least stage 3) medial sacral wound. He needs very aggressive offloading to prevent this from getting worse. To this end, he needs a low air loss bed, which the DON is pursuing. Although a 12/12/15 skin assessment identified a blister to the right heel (which is considered a stage II pressure ulcer); the wound doctor did not assess the right heel wound. On 12/17/15 at 4:00 p.m., a telephone order read for the sacral pressure ulcer should be cleaned with wound cleaner then dry. Apply skin prep to the skin around the wound. Apply a small amount of medi-honey to the open wound. Cover the entire area with optilock and secure with a tape. The dressing was to be changed Tuesday, Thursday, Sunday and as needed for saturation and soiling. -Failure: Review of the TAR showed the resident received the initial sacral ulcer treatment on 12/22/15, five days after it was ordered. The TAR also showed the resident also did not receive treatment for [REDACTED]. Moreover, no order for a low air loss bed was found in the resident's record and there was no documentation elsewhere in the record to identify when the air mattress was placed or what settings were selected to ensure the resident's offloading needs were met. (8) A 12/22/15 visit report from the wound physician stated in pertinent part, that the resident had [DIAGNOSES REDACTED]. The visit did not address the resident's right heel, which had been identified as having a blister on 12/12/15 weekly skin assessment. -Wound #1 medial sacrum measured 6cm length x4cm width x 0.2 cm depth with an area of 24 sq cm and a volume of 4.8 cubic cm post debridement. On initial inspection there was a small amount of serous drainage. The wound bed was 51-75% adherent yellow slough. The periwound was normal for texture, moisture and color. -Wound #2 right sacral was necrotic tissue (unstageable) measured 2.5cm length x 5cm width, with an area of 12.5 sq cm. There was a small amount of serous drainage noted. The wound bed was 51-75% adherent, yellow slough. The periwound skin was normal for texture, moisture and color. -Wound #3 left sacral is a Pressure Ulcer and has received an outcome of Converted. (No explanation of the term converted was identified.) -(Resident's) wounds have progressed - the DTIs that were present have opened into unstageable pressure ulcers (due to slough). This was expected and does not necessarily imply worsening. His periwound skin is in excellent condition. I would like to continue to use Santyl to help debride the remaining slough. He has a pressure reducing air mattress. As long as he is offloaded and turned frequently I do expect these to heal. He is apparently not eating much but will take in some protein shakes which is encouraging. I will also check nutritional labs. -The report included new orders for wound care to wounds #1 and #2. The new orders stated: Cleanse wound with Cleanser Protect periwound with skin prep. Apply Santyl to the wound bed -thin layer Cover with bordered gauze change daily Additional orders stated that nutrition was discussed. an order for [REDACTED]. -Failures: Review of the telephone orders in the clinical record revealed a telephone order for the new wound treatment from the 12/22/15 wound physician visit was not generated. A review of the 12/2015 TAR revealed the new orders listed were not placed on the TAR and the resident continued to receive the Tuesday/Thursday/Sunday and as needed dressing change put in place on 12/17/15. Additionally, the protein shakes three times daily did not have a telephone order; no order for the protein shake of choice was present on the 12/2015 Medication Administration Record [REDACTED] Although the wound physician referenced protein/calorie malnutrition on the 12/22/15 progress note, the clinical record did not evidence that the registered dietician (RD) was informed of this concern. No assessment from the RD on or after 12/22/15 was identified in the clinical record. There was no documentation in the clinical record of wound monitoring from 12/23/15 through 12/25/15. There was no evidence the resident's family was notified of the 12/22/15 wound physician's report. (9) The 12/26/16 weekly skin assessment stated in part, Pts skin warm and pink. Pt with open wound to coccyx-[MEDICATION NAME] treatment ordered. Pt with bruising to bilateral heels. Skin prep applied. Pt with air mattress. -Failure: No measurement of the coccyx wounds or for the heel bruising were included in the assessment. No description of the wound bed, wound edges, surrounding tissue, drainage, odor or other pertinent information was identified. (10) A nurse's note dated 12/26/15 at 3:03 p.m., stated, Bilateral heels boggy, bruised. Small open wound with minimal drainage on L (left) heel. Skin prep applied. Bilateral heels floating while in bed. Left message to DON for wound MD to evaluate bilateral heels while following up on coccyx wound. -Failure: The note did not indicate the resident's primary physician or family was informed of the heel wound(s). No order was identified for treatment of [REDACTED]. The treatment administration record for 12/2015 did not evidence that treatment of [REDACTED]. No orders regarding heel offloading were found. (11) A 12/27/15 at 8:19 p.m., nursing note stated, Remains withdrawn and isolated. Non-communicative. Refusing to get up in chair or leave room. Refusing dinner. Resistive to being turned and repositioned. Taking juice, water and nutritional supplement. Drsg (dressing) to coccyx changed. Area cleansed, skin prep to peri-wound area. Drsg saturated w Serosanguinous fluid, [MEDICATION NAME], exudate. Skin prep to heels and around scabbed area to L lateral knee. Foley patent and draining yellow urine w occasional sedimentation. Failure: Cross refer to F319; failure to address the resident's declining psychosocial condition and behaviors. In addition, no mention of the left knee wound identified in the above note was found in the clinical record. In addition, the 12/27/15 nursing note did not indicate that a physician was notified and orders obtained related to the wounds to the resident's heels or left knee. Rather, the note showed the resident continued to receive the wound treatment ordered on [DATE] instead of the new orders listed on the 12/22/15 wound physician visit. A review of telephone orders showed no new orders were obtained for treating/offloading the resident's heels, though skin prep was being applied. (12) A 12/28/15 at 3:43 p.m., nurse's note stated that the resident's family member was notified of the resident's worsening depression. The note indicated a message was left for the primary physician. No documentation about the wound was made. (13)A 12/30/15 at 8:50 p.m., nurse's note stated, Noncommunicative, withdrawn. Verbal response consists of monosyllabic answers. Lying in darkened room w shades drawn, TV off, facing wall. Declining dinner. Taking water and sm (small) amts (amounts) of juice. Refusing to remain in position to offload weight. Removes wedges using to position and/or moves to lie flat on back. -Failure: The clinical record did not evidence that the physician or resident's family was notified of the resident's offloading refusals. The note did not show that the interdisciplinary team was notified of the the resident's refusals, isolation, and poor intake. (14) A 12/31/15 visit report from the wound physician stated in pertinent part: -(Resident's) two wounds have merged into one large wound. The majority is a dry, firm desiccated necrotic tissue, but there is also slough present. I did a debridement of some of the slough and necrotic tissue. I would like to continue to use Santyl but have also ordered a wound vac - this area needs to be thoroughly debrided and a wound vac applied. (Resident) has a very serious wound here and the staff report that he has no interest in getting out of bed. He does not appear to have the same concern for his wound that the rest of us feel - I am not sure if this due to in part a lack of understanding the gravity and how much is due to a general picture of depression and lethargy .I will try to do a thorough debridement next week if the wound vac supplies are in stock. -The medial sacral wound (which had merged with the other sacral wounds) measured 8cm length x 15 cm width with an area of 120 sq cm. The wound bed was 51-75% black eschar and was considered unstageable. -The wound's duration was listed as early December. -A new treatment order was listed on the report which stated, Cleanse with Cleanser, Protect periwound with Skin Prep, Apply Santyl to wound bed - thin layer, Cover with ABD (abdominal dressing), Change daily. The wound physician did not document anything regarding wounds to the heels. (15) A review of the telephone orders revealed a 12/31/15 at 12:00 p.m., an order to change the resident's sacral wound treatment to the order directed in the wound physician's progress note. The telephone order also stated, prevalon or heel medix boots at all times for heel wounds. No order for using skin prep or any other product on the heel wounds was included on the order. -Failure: The telephone order did not show family was notified of the change to the resident's wound treatment order. (16) A 12/31/15 at 2:00 p.m., nurse's note stated, Pt seen by wound MD (physician). Wound to coccyx worse since last visit one week ago. Resident educated on importance of position changes and getting out of bed and into wheelchair to relieve pressure. Educated patient on importance of nutrition for wound healing. Pt continues to refuse to get out of bed. Wound dressing changed as ordered. A 12/31/15 at 4:38 p.m., weekly skin check documented that the resident had pressure areas to the coccyx and to the bilateral heels. The coccyx wound was 8cm x 15 cm. Right and left heels were not measured but were noted to have wound beds of black eschar. The comment field stated, Dr (doctor) discussed importance with the resident of getting up to his chair to relieve pressure off of his back. Resident reply back to the (wound) Dr I don't want to. I am fine the way that I am. Importance of eating & good nutrition to promote healing to his wounds & prevention of new wounds. Resident reply I will eat what I want & when I want. Resident had poor eye contact during the wound care & while being educated. A 12/31/15 at 5:11 p.m., nurse's note stated, Wound doctor is looking to place wound vac to the coccyx wound next week. (Central Supply) is aware & looking into ordering wound vac. (Admission director, NHA, social service director) aware of the findings of wound from today's wound visit. On duty day nurse is aware of the wound findings & came into redress wound per order. A 12/31/15 at 9:58 p.m., nurse's note stated, (resident) Easily angered and resistive to being repositioned to offload wgt (weight) from pressure areas. Pulls wedges and pillows from back and/or moves until is lying flat on back. Drsg (dressing) to coccyx C/D/I. Skin prep to bilateral heels. Protective boots in place. Quiet, withdrawn non-communicative. Ate <20% w 500cc fl (fluid) intake. Refusing to get up in w/c (wheelchair). Lying in bed in dark rm (room) w (with) lights off and door closed. Foley patent and draining clear yellow urine w occasional sedimentation. -Failure: None of the notes from 12/31/15 showed the resident's primary physician or the resident's family were notified of the concerns with the resident's worsening ulcers or regarding increasing refusal of care. (17) A 1/1/16 at 11:59 p.m., nurse's note stated, (resident) Resistive to care. Declining to get up in w/c. Moving to back when repositioned and kicking off Prevalon boots. Appetite poor. Fl intake 800cc. C/

Based on observations, resident interviews, family interviews, staff interviews, and record review, the facility failed to ensure sufficient nursing staffing to provide nursing and related services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident as determined by resident assessment and individual care plans for 16 residents (#1, #2, #3, #5, #7, #8, #10, #11, #12, #13, #14, #15, #16, #17, #18 and #22) of 22 sample residents. Specifically, the facility's failure to consistently provide sufficient nursing staff contributed to failures in resident assessment, resident qualify of life and resident quality of care as evidenced by: undignified care and services, delayed assistance with toileting and response to other resident needs, lack of supervision to keep residents safe from aggressive behaviors, elopement and falls, inadequate monitoring of residents at risk for skin breakdown. In summary, several residents experienced physical, mental and psychosocial declines such as advance pressure ulcers, worsening depression, fractures, bruises, and cuts. Insufficient nursing care also contributed to other, associated failures including communication with providers, due to staff's lack to time to complete all their assigned responsibilities. The findings included: Cross reference F241 dignity for failure to allow resident #7 to sleep in his room due to need to monitor the resident. Cross reference F253 housekeeping and maintenance services for failure of night nursing staff to clean residents #7 and #14's wheelchairs. Cross reference F278 assessment accuracy for failure to accurately assess residents #1, #17 and #18. Cross reference F279 develop comprehensive plan of care for failures to develop a comprehensive care plan for residents #1, #10, #13 and #16 for individuals with pressure ulcers and with range of motion limitations. Cross reference F281 professional standards for failures to meet nursing standards for care for residents #1, #3, #10, #11 and #12 for documentation and pressure ulcer care. Cross reference F309 provide care and services to meet highest practicable well-being for residents #1 and #5 related to [MEDICAL TREATMENT] services and management of resident pain. Cross reference F312 ADL (activities of daily living) care for dependent residents for resident #7 and #3 for failure to provide timely assistance with incontinence cares. Cross reference F314 treatment and services to prevent/heal pressure ulcers for residents #1, #2, #3, #10 and #11 for failure related to the prevention and healing of advance stage and multiple pressure ulcers developed in the facility. Cross reference F318 increase/prevent decrease in range of motion for failure to provide range of motion services for resident #16. Cross reference F323 free of accident hazards/supervision/devices for residents #5, #8, and #22 related to falls with injury, insufficient supervision of a wandering resident, and insufficient management of a resident with behaviors. Cross reference F329 unnecessary drugs for residents #2, #5, #13 and #22 for failures related to monitoring resident behaviors related to the use of [MEDICAL CONDITION] medications. Cross reference F354 full-time DON for failure to secure sufficient registered nurse staffing to comply with the requirement that the director of nursing not serve as direct care nurse in a building with 60 or more residents. Cross reference F456 essential equipment, safe operating condition for residents #7, #15 and #16 for failure to ensure resident air mattresses were on the proper setting and were in working order. I. Resident Status According to the Census and Conditions report, signed by the minimum data set coordinator (MDS) on 2/17/16, the resident census was 77. The following care needs were enumerated: -47 residents required assist of one to two staff for bathing and 20 residents were dependent for bathing. -56 residents required assist of one to two staff for dressing and one resident was dependent for dressing. -60 residents required assist of one to two staff for transfers and two residents were dependent for transfers. -60 residents required assist of one to two staff for toilet use and two residents were dependent for toilet use. -47 residents required assist of one to two staff for eating and ten residents were dependent for eating. -46 residents were occasionally or frequently incontinent of bladder. -46 residents were on a urinary toileting program. -28 residents were occasionally or frequently incontinent of bowel. -32 residents were on a bowel toileting program. -1 resident was bed fast all or most of the time and 46 residents were in a chair all or most of the time. -33 residents ambulated with assistance or an assistance device. -24 residents had contractures and two of the 24 residents with contractures developed the contractures after admission to the facility. -3 residents had pressure ulcers. None of the residents with pressure ulcer had pressure ulcers present on admission to the facility. -66 residents were receiving preventative skin care. -36 residents had documented signs and symptoms of depression. -33 residents had dementia-related diagnoses. -34 residents had behavioral healthcare needs. -49 residents were on psychoactive medications including 23 residents on antipsychotic medications. -44 residents were on a pain management program. -15 residents were receiving rehabilitation services. -5 residents had significant, unplanned weight loss. II. Observations/Interviews On 2/14/16 at 4:40 a.m., an observation of a posting outside the human resource office of the facility stated the facility had openings for the following positions: registered nurse (RN) - full time, part time and as needed; licensed practical nurse (LPN) - full time, part time and as needed; certified nurse aide; activity assistant - part time and as needed; director of nursing - salary; transportation - full time; receptionist; and business office manager - salary. On 2/14/16 at 4:45 a.m., observation of the building revealed the night shift was staffed with three total CNAs, two LPNs and an RN. CNAs #1 and #2 were observed on the long term care hall with LPNs #1 and #2. LPN #1 stated there were 65 residents on the long term care hall and the short term hall had 12 residents. LPN #1 confirmed the long term care unit was short one CNA on the night shift. RN #7 and CNA #6 were observed providing cares on the short term care hall. On 2/14/16 at 5:10 a.m., the call light was on in room [ROOM NUMBER] (long term care hall). Upon entering the room, the resident in the A bed stated that he had been waiting for 10 minutes for help with his soiled brief. The resident reported long waits for help. A bowel movement (BM) odor was present in the room. On 2/14/16 at 5:16 a.m., LPN #2 was observed to enter room [ROOM NUMBER] without knocking, turned off the call light without speaking to the residents, and exited the room. The resident did not have a brief change. On 2/14/16 at 5:17 a.m., the resident in 308A was approached about his call light. The resident stated the nurse came in and turned it off without asking about his needs. The resident in 308A stated he felt bad sitting in a soiled brief. The resident in 308 B (roommate) then stated the nurse turned the call light off and left. A BM odor was present in the room. Continuous observation of room [ROOM NUMBER] through 5:30 a.m., revealed no staff entered the room to provide incontinence assistance to the resident. On 2/14/16 at 5:49 a.m., the call light was on in room [ROOM NUMBER]. LPN #2 entered the room, without knocking, at 5:50 a.m., and turned off the call light without speaking to the residents in the room. The LPN then exited the room. On 2/14/16 at 5:51 a.m., LPN #1 entered room [ROOM NUMBER] with a glucometer and shut the door. The LPN exited the room at 5:55 a.m., the LPN exited room [ROOM NUMBER] with the glucometer. The LPN was not carrying a bag of refuse suggesting no brief change was provided. On 2/14/16 at 8:17 a.m., two nurses (LPNs #9 and #5) were observed sharing three medication carts by the dining room. LPN #9 stated that they were short one nurse for the day shift. III. Resident Interviews 2/14/16 at 7:47 a.m., a resident requesting anonymity stated she wanted to express a concern about staffing. According to the resident, there was insufficient staff to timely respond to resident needs. The resident reported s/he was made to sit in a wet brief on multiple occasions for hours. The resident felt (expletive) lousy when left to sit in a wet incontinence brief. On 2/17/16 at 2:17 p.m., a different resident requesting anonymity stated the staffing was not good at the facility. The resident reported long waits for help overnight and on the weekends. The resident stated that the facility was short one certified (CNA) on the night shift on Sunday (2/14/16) and was short a nurse and a CNA on the day shift on the same Sunday. The resident reported informing facility staff about staffing concerns with no effect. IV. Family Interviews On 2/17/16 at 3:50 p.m. a family member requesting anonymity said there is not enough staff for the residents to get what they need. On 2/18/16 at 4:45 p.m., resident #7's family member stated that staffing levels in the building were horrible. The family member reported seeing many residents sitting in poop and pee during daily visit to the facility. The family member reported that her family member was often found very wet and soiled because staff is unable to provide timely incontinence cares. The family member stated resident #7 could wait more than four hours before a check and change. The family member reported the resident is made to stay in his geri-chair because there is not enough staff to do rounds and keep an eye on the resident. The family member stated the lack of staffing contributed to a lack of dignity in the facility. On 2/23/16 at 1:20 p.m., an interview with resident #8's daughter revealed the facility was inadequately staffed with nurses and CNAs to meet resident needs. According to the family member, the resident was not bathed for weeks when she was admitted to the facility three months ago. The family member stated her mother would wait more than 30 minutes for call light responses and would get frustrated and call her. The daughter reported meal assistance was problem as the resident did not receive her dinner for the first three nights of her stay at the stay. Per the daughter, toileting/incontinence care was not timely provided. The daughter stated her mother's roommate was left to sit in her own feces for hours because staff did not come to check on her. On 2/24/16 at 1:42 p.m., a family member for resident #12 stated that nurses in the building were in short supply. Due to the lack of nurses, the resident did not get the physician-prescribed lotion applied to his legs. The family member stated that she identified wounds on the resident's legs that nurses should have found while providing the prescribed lotion. The family member stated the low staffing was made worse by the facility taking in many residents with behaviors that over-utilize staff time. The family member stated she approached corporate leadership about staffing concerns and was told the building's staffing was adequate. V. Staff Interviews On 2/17/16 at 7:30 a.m., an interview with LPN #9 revealed it was not uncommon to work short of nurses on the long term care hall. The LPN stated that when fully staffed, each nurse has one hall and 21-22 residents. The nurse is responsible for medications, treatments, all follow-up, all new/change orders, notifications, documentation and assessments on the hall. The LPN stated the nurses were also responsible for all admissions and discharges on the halls. When short staff, the LPN stated it was impossible to meet the workload and residents suffered. On 2/17/16 at 9:45a.m., staff member #19 stated the lack of nursing staff was a huge issue in the building. The staff member stated there was a finite amount of work one person could accomplish in a shift no matter how much staff cared. The staff member stated inadequate nursing staff resulted in residents being neglected. The staff member stated the nursing home administrator (NHA) was aware of the staffing issues because nurses had brought up the concern. On 2/17/16 at 2:06 p.m., and 2/23/16 at 6:35 p.m., an interview and follow-up with staff member #6 revealed that that there had been a lot of turnover in nursing staff resulting in many position/schedule vacancies. The staff member stated the facility was attempting to fill some open shifts with agency but staffing levels were regularly inconsistent. The staff member stated that working short has resulted in not being able to meet resident needs with turning, positioning, toileting and personal interactions with the residents. The staff member stated there had not been a restorative program in place in the building since the summer. Residents with range of motion needs and needs to maintain activities of daily living skills were not having those needs met. On 2/17/16 at 4:24 p.m., staff #2 stated that the bath aide would get pulled to the floor at times when the facility was short of CNAs. When the bath aide was pulled to the floor, residents did not receive scheduled bathing opportunities. The staff member stated staffing was often short on the weekends. The staff member reported the resident #5 fell and fractured a hip when the building was short staffed a week or two earlier. Cross refer F323 for further details On 2/17/16 at 4:50 p.m., staff #13 stated that nurse and CNA staffing at the building was bad. The staff member stated the facility was now using some pool staff to fill the holes in the schedule. The staff stated that when they work short, staff try their best, but it is hard to meet resident needs. The staff member expressed feeling frustrated about providing poor care due to insufficient staffing levels. The staff member stated when CNA staff was short, an incontinent resident would get changed once or twice a shift instead of three or four times a shift. The staff stated that when nurses were short, medications were late and documentation could be overlooked. On 2/17/16 at 5:20 p.m., an interview with staff #9 revealed the facility was often short of nurses and CNAs. The staff member stated that when the minimum scheduled staffing levels were not met, residents care suffered and care was impacted. Residents would not receive requested assistance timely and scheduled assistance like positioning and incontinence care were delayed or missed. The staff member had brought staffing concerns to the attention of nursing and facility leadership. The staff member stated the NHA dismissed the problem. On 2/18/16 at 7:00 a.m., staff member #8 stated the building was short of nurses and CNAs over the weekend. The staff member stated that the priority is answering call lights, so when staff is short it was difficult to get to routine cares due to call light responses. The staff stated that routine cares like turning and positioning were skipped or delayed. The staff member stated that resident care needs were not met when the facility was understaffed. On 2/18/16 at 9:23 a.m., CNA #16 stated the facility was putting on a show (during survey) with all the extra staff. The CNA stated the long term unit was lucky to have four CNAs and a bath aide for 65 residents on the day shift. The CNA stated there had been more skin breakdown in recent months, which the CNA attributed to understaffing. On 2/18/16 at 5:20 p.m., an interview with staff #7 revealed the building had a staffing insufficiency. The staff member stated the long term care unit worked short of nurses regularly. The staff member stated that even when the nursing staff was scheduled to the planned minimum levels, the nurse workload was difficult to meet. The staff member stated floor nurses were expected to give all medications, treatments, write notes, follow-up with as needed medications, and perform the duties of a charge nurse. The staff member stated that because of the short staffing things that were not OK happened in the building. On 2/19/16 at 10:02 a.m., LPN #7 stated it was common to work short of nurses and CNAs. The LPN stated staff did their best, but could not meet resident needs with open positions on a shift. On 2/23/16 at 8:00 a.m., staff scheduler, who also worked the floor as a CNA and who was the medical records person, stated she took over in staffing over a month ago. The scheduler stated she made every effort to staff to the planned minimums. The planned minimums were: -Long term care unit day shift: Three nurses, five CNAs and a bath aide. -Long term care unit evening shift: Three nurses, four/five CNAs. -Long term care unit night shift: Two nurses, Two CNAs. -Short term care unit: One nurse and one CNA day/evening/night shifts The scheduler stated more staff might be added if the census was up and staff could be reduced if the census was down. (Cross reference to F356 Staff Posting for observations, interviews and record reviews showing the facility failed to maintain documentation about nursing staff hours in conjunction with resident census levels.) On 2/23/16 at 10:44 a.m., an interview with the minimum data set (MDS) coordinator revealed that she had attempted to revive the restorative program. According to the MDS coordinator, the NHA had told her there were not enough CNAs to provide restorative services. On 2/23/16 at 4:25 p.m., an interview with the interim director of nursing (IDON) revealed the IDON, too, felt there was a staffing problem in the building. According to the IDON, the staffing problem predated her tenure in the IDON position. The IDON stated the NHA has done very little to address the problem. On 2/24/16 at 9:23 a.m. RN #6 stated the facility needed more staff. The RN said there had been so much turnover from week to week that nobody knew who was working. The nurse said the morning aides were especially overwhelmed. According to the nurse, there were 13 residents on the short term hall (rehab hall), including some long-term residents. The nurse explained the rehab hall had a few residents who required a Hoyer lift, and because there was only one aide on this hall the nurse had to drop what they were doing each time the lift was needed to assist. They tend to piecemeal (ask staff to arrive early or stay late on scheduled shifts) the schedule. On 2/24/16 at 1:16 p.m., the NHA stated he had been addressing staffing shortages by using a staffing agency, using bonuses to encourage hiring, and by using shift bonuses for current staff that pick up extra shifts. The NHA stated the market for hiring was very difficult due to the facility's location. The NHA stated the he felt that shifts were being adequately covered. VI. Other Interviews On 2/18/16 at 6:06 a.m., a RN from an outside (hospice) agency providing cares to a resident in the building stated she had concerns with staffing in the building. According to the nurse, when visiting clients in the facility, she noticed residents in the same dirty clothes for multiple days. The RN stated that she had observed resident #7 in puddles of urine from delayed incontinence cares. The RN stated a resident that she was seeing had recently developed a pressure ulcer on the coccyx. On 2/18/16 at 10:30 a.m., an interview with the psychologist who provided mental health services in the building revealed he felt there was not enough staff to keep an eye on residents in the building. The psychologist stated that he observed resident #21 struggling to navigate back into the building using a wheelchair. He assisted the resident back in. The psychologist stated a short time later the resident was found in the driveway of the building with a fractured clavicle. The psychologist stated he had heard about resident #5 being found on the floor in the dining room on the weekend when staffing was short. The psychologist expressed concerns with the building accepting more residents with behaviors without adequate, prepared staff to meet the needs of behavioral clients. On 2/22/16 at 9:00 a.m., a regular visitor to the facility stated she received numerous complaints about staffing at the building. The visitor stated she had received as many as 19 calls in one day about the facility's lack of staff. On 2/24/16 at 12:00 p.m., an interview with a physician who provided medical services to many residents in the building stated the building was understaffed with nurses and CNAs. The physician stated the understaffing has resulted in the nurses failing to provide vital communications. The physician stated she had to hunt for nurses to get updates on residents; found laboratory orders were not being requested; found laboratory results were not being placed in charts; and had increased difficulty with residents being scheduled for follow-up appointments with outside providers. The physician stated she had begun having her transcriptionist arrive early so that he could call for all lab results in order to have the lab results available for review during resident care visits. The physician stated that nurses and nursing leadership no longer know what is going on with residents because of the short staffing. VII. Record Review A. Resident Council Minutes The resident council minutes for three months revealed residents felt call light response time was slow, particularly after dinner. 12/8/15 Resident Council Some residents expressed concern about their call lights not being answered in a timely manner. Unresolved according to (eight resident names listed that included residents #1 and #21). 1/12/16 Resident Council Some residents expressed concern about their call lights not being answered in a timely manner. -Unresolved - many residents stated still an issue especially after dinner. (Staffing Scheduler) stated she is increasing her sources for hiring by going to CNA schools. She stated she is working very hard with calling staff to cover for all call offs etc. (Staffing Scheduler) is also working to interview and hire new nurses. 2/9/16 Resident Council Some residents expressed concern about their call lights not being answered in a timely manner. - Residents feel it has gotten a little better but they continue to feel they need more aides especially after dinner. B. Staffing Sheets A review of the staffing sheets from 12/1/15 through 2/23/16 revealed that the facility regularly had unfilled/open positions for nurses and nurse aides during various shifts on both units. -12/1/15 there was no CNA on the short term unit (STU) after 6:30 p.m., and the long term unit (LTU) had was short one CNA from 2:30 a.m., until 6:30 a.m. There were two CNAs for all residents in the building from 2:30 a.m., until 6:30 a.m. -12/2/15 there was no CNA for the STU from 6:30 p.m., until 6:30 a.m. -12/5/15 the LTU was short one nurse and one CNA for the overnight shift. The evening shift was short one CNA after 6:30 p.m. -12/6/15 there was no CNA for the STU from 6:30 p.m., until 6:30 a.m. -12/7/15 there was no CNA for the STU from 6:30 p.m., until 6:30 a.m. -12/13/15 there were two CNAs for the whole building on the overnight shift. -12/14/15 there was no CNA on the STU from 6:30 p.m., until 10:30 p.m. -12/15/15 the LTU was short on CNAs from 2:30 p.m. to 6:00 p.m. The STU had no CNA from on the evening or overnight shift. -12/17/15 the STU had no nurse the day and evening shift. The LTU was short a nurse from 8:00 p.m., until 10:30 p.m., and was short one CNA from 2:30 until 6:00 p.m. -12/18/16 the STU had no CNA from 10:00 a.m., until 10:30 p.m. The LTU was short one CNA from 10:00 a.m., until 6:00 p.m. -12/20/15 the LTU was short one nurse on the day shift and one nurse overnight shift. -12/25/15 the LTU was short one nurse on the day shift and one nurse on the overnight shift. -12/26/15 the LTU was short a bath aide on the day shift and a nurse on the overnight shift. The STU was short a CNA on the overnight shift. -12/28/15 the LTU was short one CNA on the evening shift. -12/29/15 the LTU was short one nurse on the overnight shift. -12/31/15 the LTU was short one CNA on the overnight shift. -1/1/16 the LTU was short one nurse on the day shift, one nurse on the overnight shift, one bath aide on the day shift, one CNA on the day shift and one CNA on the overnight shift. -1/2/16 the LTU was short one nurse on the day shift and one CNA from 2:30 p.m., until 6:00 p.m. -1/3/16 the LTU was short one nurse on the evening shift. -1/4/16 the LTU was short one nurse on the day shift, one nurse on the evening shift and two CNAs from 6:30 p.m., until 10:30 p.m. -1/5/16 the LTU was short one nurse on the overnight shift. -1/6/16 the LTU was short one nurse on the overnight shift. -1/7/16 the LTU was short one nurse for the day shift. The STU was short one nurse from 6:30 a.m., until 10:00 a.m. -1/8/16 the LTU was short one CNA from 2:30 p.m., until 6:30 p.m. -1/9/16 the LTU was short one CNA for the day shift and one CNA for the whole evening shift and was short a second CNA for half of the evening shift. The STU was short one CNA for the day shift. -1/10/16 the LTU was short one nurse on the evening shift and one CNA for the evening shift. -1/11/16 the LTU was short one CNA from 6:30 p.m., until 10:30 p.m. -1/12/16 the LTU was short one nurse on the overnight shift. -1/16/16 the LTU was short one nurse on the day shift, one nurse on the evening shift, and a CNA on the overnight shift beginning at 1:30 a.m. -1/17/16 the LTU was short one nurse on the day shift. -1/18/16 the LTU was short one nurse on the day shift and one CNA from 2:30 p.m. until 6:00 p.m. -1/19/16 the LTU was short one CNA for the whole day shift and was short a second CNA from 6:30 a.m., until 10:00 a.m. The LTU was short two CNAs on the evening shift and one CNA and one nurse on the overnight shift. -1/10/16 The LTU was short two CNAs for the whole day shift and a third CNA from 6:30 a.m., until 10:00 a.m., on the day shift. The LTU was short one CNA for half of the evening shift. -1/21/16 the LTU was short one CNA on the day shift. -1/22/16 the LTU was short one nurse for the day shift. The STU was short one nurse for the day and half of the evening shift. -1/23/16 the LTU was short one nurse after 10:00 a.m., on the day shift. -1/24/16 the LTU was short one CNA on the day shift and one CNA on the overnight shift after 3:30 a.m. -1/25/16 the LTU was short one nurse after the morning med pass and was short one CNA after 10:00 a.m. The STU was short one nurse from 10:00 a.m., until 2:30 p.m. -1/26/16 the LTU was short one CNA on the day shift. -1/29/16 the LTU was short one CNA on the day shift until 10:00 a.m. -2/1/16 the LTU was short one nurse and one CNA on the day shift and one nurse for half of the evening shift. The STU was short one nurse for half of the evening shift and the overnight shift. -2/2/16 the LTU was short three CNAs on the day shift. The STU was short one nurse on the day shift. -2/4/16 the LTU was short one nurse on the day shift. -2/6/16 the LTU was short one nurse on the evening shift CNA for the evening shift and one CNA on the overnight shift. -2/7/16 the LTU was short two CNAs for the day shift and one nurse for the evening shift. -2/8/16 the LTU was short one nurse for an undefined portion of the day shift and one CNA on the day shift. -2/9/16 the LTU was short one CNA of the whole day shift and was short two additional CNAs for a portion of the day shift. -2/10/16 the LTU was short one CNA on the day shift. -2/12/16 the LTU was short one CNA on the day shift. -2/13/16 the LTU was not listed as being short on the overnight shift on 2/13/14; however observation and staff interview confirmed LTU was short one CNA on that shift. -2/14/16 the LTU was short one CNA on the day shift. The LTU was short one nurse on the day shift per observation and staff interview; however this was not captured on the staffing sheet. -2/15/16 the LTU was short one nurse on the day shift and one nurse on the evening shift. -2/16/16 the LTU was short one CNA on the day shift and one CNA on the evening shift. -2/18/16 the LTU was short one CNA after 2:00 a.m. -2/19/16 the LTU was short one CNA on the overnight shift. -2/21/16 the LTU was short one CNA on the day shift. The STU was short one CNA on the night shift.

Based on observations and interviews, the facility leadership failed to ensure facility operations were administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 16 (residents #1, #2, #3, #5, #7, #8, #10, #11, #12. #13, #14, #15, #16, #17, #18 and #22) of 22 sample residents and potentially each resident of the facility. Specifically, the administrator's failures to effectively administer the building resulted in staffing shortages; lapsed and nullified contracts with outside providers; lack of quality assurance and assessment; and non-compliance resulting in pattern-level immediate jeopardy to resident health and safety and multiple instances of isolated resident actual harm that was not immediate jeopardy. The findings include: Cross reference F250 Social Services; failure to ensure social service staff were meeting resident needs related to discharge planning, mental health services for resident #2 and behavior monitoring for residents #2, #5, #13 and #22 in the presence of [MEDICAL CONDITION] medication usage for the treatment of [REDACTED].#2 and pattern of potential for more than minimal harm for residents #2, #5, #13 and #22. Cross reference F314 Pressure Ulcers; failure to provide treatment and services to prevent and heal the development of advance stage and multiple pressure ulcers for residents #1, #2, #3, #10 and #11 for failure developed in the facility. The failures contributed to a pattern level situation of immediate jeopardy to resident health. Cross reference F319 Treatment and Services for Mental Psychosocial Difficulties; failure identify and address mental health service needs for resident #2. This failure resulted in actual harm at an isolated level for resident #2. Cross reference F323 Free of Accident Hazards/Supervision/Devices; failure to provide residents #5, #8, and #22 care and services to prevent falls with injury and elopement. These failures resulted in actual harm at an isolated level for residents #5 and #8. Cross reference F329 Unnecessary Drugs; failures related to monitoring resident behaviors related to the use of [MEDICAL CONDITION] medications. The failures represented pattern with the potential for minimal harm for residents #2, #5, #13 and #22. Cross reference F353 Sufficient Nursing Staff; failures to provide sufficient nursing staff to meet resident needs. The failure to provide sufficient nursing staff contributed to pattern level actual harm that was immediate jeopardy to residents #1, #2, #3, #10 and #11 for pressure ulcers; and actual harm for pain and falls for resident #5. Cross reference F354 Full-time DON; failure secure sufficient registered nurse staffing to comply with the requirement that the director of nursing not serve as direct care nurse in a building with 60 or more residents. The failure to ensure the DON was available to conduct responsibilities of the DON position contributed to actual harm for residents #1, #2, #3, #10, #11 (pressure ulcers) and for resident #5 related to falls and pain management. Cross reference F456 Essential Equipment, Safe Operating Condition for residents #7, #15 and #16 for failure to ensure resident air mattresses were on the proper setting and were in working order. Cross reference F500 Use of Outside Resources; failure secure and maintain contracts with the registered dietician and other outside providers of service. The administration's failures in this area contributed to isolated potential for more than minimal harm for resident #17 who experienced unplanned weight loss cited in F325 Maintain Nutritional Status and residents #1 and #18 who received [MEDICAL TREATMENT] services. Cross reference F501 Medical Director; failure to have an active Medical Director coordinating medical care in the facility and providing oversight of resident care policies. Cross reference F520 Quality Assessment and Assurance; failure to conduct quality assessment and assurance activities. The failure to implement a quality assurance process for failures related to resident #2's pressure ulcers contributed to continued failures in pressure ulcer prevention and healing impacting residents #1, #3, #10 and #11 at a pattern level of actual harm. The failure to implement quality assurance related to falls after previous deficient practice was cited on a survey exiting [DATE] and contributed actual harm related to falls for residents #5. I. Provider Interviews Interviews with providers revealed the administrator was not approachable and did not maintain a good working relationship with individuals that had insight and suggestions for the operation of the facility. Contracts for services expired and necessary services were not furnished. (1) An RN from an outside (hospice) agency providing cares to a resident in the building was interviewed on [DATE] at 6:06 a.m. The RN stated she had noticed a decline in care and services in the building. She said that when visiting clients in the facility, she noticed residents in the same dirty clothes for multiple days. The RN stated she had observed resident #7 in puddles of urine from delayed incontinence cares. The RN stated a resident that she was seeing in had recently developed a pressure ulcer on the coccyx. The RN stated she noticed many of the long-time staff had departed and believed their departure was related to the conduct of the current nursing home administrator (NHA). (2) A mental health practitioner (Masters level prepared) who provided services at the facility was interviewed on [DATE] at 10:17 a.m. The practitioner said she had concerns about care in the building. The practitioner stated that when she tried to approach the NHA with her concerns about resident care, she found him unreceptive and dismissive. (3) A psychologist who provided services at the facility was interviewed on [DATE] at 10:30 a.m., and 2:48 p.m. The psychologist stated he had attempted to address care concerns related to resident #2's placement at the facility with the NHA. The psychologist stated NHA was unwilling to consider the concerns. The psychologist said that, in its present state, the facility did not present an atmosphere of safety for getting needs met. (4) The registered dietician (RD) providing dietician consulting service to the building was interviewed on [DATE] at 10:01 a.m. The RD stated the building administration had allowed the contract with the consulting company to lapse due to non-payment. The RD stated the NHA was well aware of the lapsed contract. The RD stated the facility had no dietician providing services from [DATE] until the contract was renewed around [DATE]. (5) A physician providing care to numerous residents in the facility was interviewed on [DATE] at 12:00 p.m. The physician stated the building did not have effective leadership from the NHA. The physician attributed failures in care, communication difficulties and a general decline in the building's service to the current NHA. The physician reported attempting to introduce herself to the NHA when the NHA assumed leadership in the building. The physician stated that the NHA held his hand up to her face and informed her that he did not have time for her. The physician stated this was the only time she had spoken with the NHA. (6) The facility medical director was interviewed after the survey exit on [DATE]. The medical director stated he had not been paid for his services for six months and the NHA had not remedied the non-payment situation until the concern was brought forth on survey. The medical director had not participated in quality assurance activities in the building during the NHA's tenure. II. Family Interviews Family member interviews attributed the facility's care and service concerns to the NHA. (1) An interested family member who daily visited resident #7 was interviewed on [DATE] at 4:45 p.m. The family member stated the facility had begun having staffing and care problems after the NHA assumed leadership of the building. The family member stated that many of the long-term staff had departed and more still were looking for other jobs. The family member stated the NHA had hired his spouse to head the social services department. The family member stated that the nursing staff that questioned the social services director (SSD) or the NHA were let go. The family member stated the NHA removed an effective director of nursing in lieu of the current, inexperienced interim director of nursing. The family member reported that NHA's attendance at the building was concerning because his hours in the building and his availability to residents and family was minimal. The family member reported that when the NHA was in the building, his office door was closed. The family member stated the NHA did not make rounds of the building to ensure things were operating properly. (2) An interested family member for resident #8 was interviewed on [DATE] at 1:20 p.m. The family member stated the NHA was ineffective. The family member stated the NHA was unreceptive to attempts to address concerns about the care and services offered in the building. Per the family member, the NHA was often behind closed doors with the SSD. (3) An interested family member for resident #12 was interviewed on [DATE] at 1:42 p.m. The family member stated that current NHA's performance had contributed to a decline in the level of care and services available to facility residents. The family member reported the NHA's conduct had caused many long-tenured staff to leave. The family member stated the NHA seemed unaware of the building's problems. III. Staff Interviews Staff member interviews revealed that the NHA was not receptive to their input. The NHA reportedly dismissed or retaliated against staff members for their attempts to broach concerns about resident care, facility staffing, and other leadership-level issues. (1) Staff member #19, interviewed on [DATE] at 8:15 a.m. said the building was on a downward spiral since the current NHA took over. The staff member reported the NHA arrived at 9:00 a.m., and then left at 11:30 a.m. The staff member stated the NHA would return at 1:30 p.m., and left for evening by 4:00 p.m. The staff member she felt the NHA was not approachable and said his door was usually closed. (3) Staff member #16 interviewed on [DATE] at 9:35 a.m., stated the facility had ceased having a morning meeting where resident care and facility concerns were addressed. The staff member stated the NHA created the staffing problem in the building by firing staff that made inquiries about concerns with resident cares. According to the staff member, the remaining staff was afraid to speak up and was looking for work elsewhere. The staff member reported the NHA seemed unconcerned about staffing. The staff member reported the NHA made a joke to staff about having a good time in reference to working short staffed over a weekend. (4) Staff member #6, interviewed on [DATE] at 2:10 p.m., said the facility's administration was not supportive and was disconnected from the issues in the building. The staff member stated s/he tried to bring the lack of staff training and in-servicing to the NHA's attention with no effect. The staff member reported the NHA was usually behind closed doors, in his office, with the SSD. (5) Staff member #13, interviewed on [DATE] at 4:40 p.m., stated that taking concerns to the NHA was not effective. When staff made inquiries about concerns, the NHA would inform them it was not their business. The staff member stated the NHA was not concerned with staff thoughts or opinions, because he did not venture out into the building to ask about them. The staff member stated she felt like the NHA was not effective in running the facility. (6) Staff member #5, interviewed on [DATE] at 5:25 p.m., stated the NHA was not effective. The staff member arrived at this opinion due to persistent staffing and supply shortages. The staff member stated the NHA was dismissive when floor staff approached him with concerns about cares or other problems. (7) Staff member #28, interviewed on [DATE] at 9:25 a.m., stated the NHA was not effective. The staff member explained effective leadership did not allow the conditions that existed in the building to persist. The staff member reported regular shortages of food, supplies and staff. The staff member stated the NHA did not appear to know what was going on in the building. (8) Staff member #7 interviewed on [DATE] at 5:20 p.m., stated the NHA did not provide leadership for the facility. The staff member stated the NHA had not addressed staff shortages. (9) The minimum data set (MDS) coordinator, interviewed on [DATE] at 10:44 a.m., revealed she had approached the NHA regarding reviving the restorative nursing program. (Cross refer F318 for details) The MDS coordinator stated the NHA was not interested in considering her proposal. The facility continued to be without a restorative nursing program even though the building had 24 residents with contractures according to the Census and Conditions form completed by the MDS coordinator on [DATE]. IV. Corporate and Administrator Interviews The regional vice president (RVP) was interviewed on [DATE] at 1:10 p.m. The RVP stated she believed the NHA exercised questionable judgment, stating he had fired a competent, experienced DON and elected to promote the current IDON who had no experience in long term care. The RVP stated the NHA did not communicate the concerns about the buildings operations to the corporate office. The RVP stated she felt the NHA had been pulling the wool over her eyes about the state of the facility. The NHA was interviewed on [DATE] at 1:16 p.m. The NHA stated he thought the facility provided acceptable care and service to its residents.

Based on observations, interviews and record review, the facility failed to maintain a quality assessment and assurance committee consisting the director of nursing services; a physician; and at least 3 other members of the facility's staff; failed to meet at least quarterly to identify issues; and failed develop and implement appropriate plans of action to correct identified quality deficiencies involving facility residents. The facility failures included: -A failure to ensure that the quality assessment and assurance committee (QAAC) included a physician -A failure to convene meetings on at least a quarterly basis -A failure to identify and address previously cited quality concerns that were isolated level actual harm at F323 Accident Hazards from an abbreviated survey exiting 12/10/15. -A failure to identify and address new quality concerns that comprised a pattern of actual harm that was immediate jeopardy under F314 Pressure Ulcers for residents #1, #2, #3, #10 and #11. -A failure to identify and address new quality concerns that comprised a pattern of actual harm under F353 Sufficient Nursing Staffing related to inadequate pressure ulcer care, insufficient supervision with falls with injury, and inadequate pain management, as well as other deficiencies in quality of life and quality of care with the potential for more than minimal harm. -A failure to identify and address new quality concerns that comprised isolated level actual harm at F250 Social Services for resident #2, F309 Care and Services for resident #5, F319 Mental Health Services for resident #2 and F323 Accident Hazards for resident #5 and #8. The findings included: Cross reference F250 Social Services for failure to ensure social service staff were meeting resident needs related to discharge planning, mental health services for resident #2 and behavior monitoring for residents #2, #5, #13 and #22 in the presence of [MEDICAL CONDITION] medication usage for the treatment of [REDACTED].#2 and pattern potential for minimal harm for residents #2, #5, #13 and #22. Cross reference F314 Treatment and Services to Prevent/Heal Pressure Ulcers for residents #1, #2, #3, #10 and #11 for failure related to the prevention and healing of advance stage and multiple pressure ulcers developed in the facility. The failures contributed to a pattern level situation of immediate jeopardy to resident health. Cross reference F319 Treatment and Services for Mental Psychosocial Difficulties for failure identify and address mental health service needs for resident #2. This failure resulted in actual harm at an isolated level for resident #2. Cross reference F323 Free of Accident Hazards/Supervision/Devices for residents #5, #8, and #22 related to falls with injury and insufficient supervision of a wandering resident These failures resulted in actual harm at an isolated level. Cross reference F329 Unnecessary Drugs for residents #2, #5, #13 and #22 for failures related to monitoring resident behaviors related to the use of [MEDICAL CONDITION] medications. The failures represented pattern level with potential for more than minimal harm for the identified residents. Cross reference F353 Sufficient Nursing Staff for failures to provide sufficient nursing staff to meet resident needs. The failure to provide sufficient nursing staff contributed to pattern level actual harm that was immediate jeopardy to residents #1, #2, #3, #10 and #11 under F314 pressure ulcers and actual harm for pain and falls for resident #5 as well as other deficiencies in quality of life and quality of care with the potential for more than minimal harm. Cross reference F354 Full-time DON for failure secure sufficient registered nurse staffing to comply with the requirement that the director of nursing not serve as direct care nurse in a building with 60 or more residents. The failure to ensure the DON was available to conduct responsibilities of the DON position contributed to the potential for more than minimal harm that was widespread Cross reference F456 Essential Equipment, Safe Operating Condition for residents #7, #15 and #16 for failure to ensure resident air mattresses were on the proper setting and were in working order. I. QAAC Composition A. Interviews On 2/24/16 at 1:16 p.m., an interview with the nursing home administrator (NHA) revealed the QAAC included the medical director as the committee physician, NHA, director of nursing (DON), assistant DON (ADON), minimum data set (MDS) coordinator, medical records, activities, dietary, and social services. The NHA acknowledged he had assumed leadership of the building in September 2015. On 12/29/16 the medical director stated he had not attended a QAAC meeting at the facility for more than six months. B. Record Review The NHA stated on 2/24/16 at 1:16 p.m., that the QAAC sign in sheets were maintained by medical records. The NHA was able to produce three QAAC sign in sheets for QAAC meetings convened by previous administrators only. A review of an undated QAAC sign in sheets, provided by the NHA on 2/24/16 at 2:04 p.m., showed the last QAAC meeting on an unknown date (the sign in sheet was undated) was conducted by the previous NHA that departed in August 2015. No additional QAAC sign in sheets were furnished by the facility. II. QAAC Meeting Frequency A. Interviews On 2/24/16 at 10:00 a.m., the interim DON (IDON) stated that she had not attended a QAAC committee meeting as either IDON or the ADON during her time at the facility. The IDON stated she started work at the facility in October 2015. On 2/24/16 at 1:16 p.m., an interview with the NHA stated he was required to convene the QAAC no more than quarterly. The NHA stated that he last convened the QAAC in November 2015. The NHA stated as February was not yet over he was still in compliance. When asked to produce sign-in sheets for the November QAAC meeting, the NHA stated that he may have convened the last meeting in October 2015. B. Record Review No sign-in/attendance records evidencing a QAAC meeting during the NHA's tenure at the building, which started September 2015, were furnished for review by the facility. III. Repeat Deficiency Cross Reference to F323 Free of Accident Hazards/Supervision/Devices for resident #5 and #8 for falls. The abbreviated survey exiting 12/10/15 cited F323 for falls at isolated level, actual harm. For the abbreviated survey exiting 2/24/16 F323 was cited for falls at isolated level, actual harm. On 2/24/16 at 1:16 p.m., the NHA stated that the QAAC had not met since the exit of the 12/10/15 abbreviated survey. No quality assurance activity had been conducted to address falls in the building. IV. Additional Deficient Practice Cross reference F314 Treatment and Services to Prevent/Heal Pressure Ulcers for facility awareness of resident #2's multiple and advanced stage pressure ulcers. The facility's failure to identify/investigate contributing factors to the formation of resident #2's pressure ulcers and then initiate QAAC activities to mitigate such factors for other residents contributed to the formation of multiple and advanced pressure ulcers for residents #1, #3, #10 and #11. The failures contributed to a pattern level situation of immediate jeopardy to resident health. A. Staff Interviews Licensed practical nurse (LPN) #9 was interviewed on 2/17/16 at 9:40 a.m. The LPN stated she did not know what the quality assurance committee was at the facility, who attended the committee, or how to bring a quality concern to the committee for consideration. LPN #4 was interviewed on 2/17/16 at 9:50 a.m. The LPN stated, What's that? I have never heard of that committee, when asked about her knowledge of the quality assurance committee at the facility. Certified nurse aide (CNA) #14 was interviewed on 2/17/6 at 2:06 p.m. The CNA stated she was not aware the facility currently had a quality assurance committee. The CNA stated that nursing staff's quality concerns were not heard by leadership. The CNA was unaware of any QAAC activities or education provided related to pressure ulcers. The CNA stated she was not aware of any quality assurance related to resident behaviors or mental health. CNA #16 was interviewed on 2/17/16 at 4:24 p.m. The CNA stated she did not know anything about the QAAC at the facility. The CNA stated she was unaware of any education or training being offered to staff related to pressure ulcers or resident mental health and behaviors. LPN #6 was interviewed on 2/17/16 at 4:41 p.m. The LPN stated she had no idea if he facility had QAAC. The LPN stated facility leadership did not consult floor staff for solutions to problems. Registered nurse (RN) #5 was interviewed on 2/17/16 at 5:20 a.m. The RN stated she was unaware of QAAC activities in the building. The RN stated no recent education or training activities had been offered related to pressure wounds. B. Leadership Interview On 2/24/16 at 1:16 p.m., the NHA stated that the QAAC had been focusing on expedited meal service and food quality. The NHA did not identify QAAC activity related to F 241 Dignity, F250 Social Services, F279 Comprehensive Care Plans, F309 Care and Services, F312 Activities of Daily Living for Dependent Residents, F314 Pressure Ulcers, F319 Treatment and Services for Mental Psychosocial Difficulties, F323 Accident Hazards, F325 Maintain Nutritional Status, and F329 Unnecessary Drugs. Cross reference F241, F279, F309, F312, and F325 (in addition to the deficiencies cross referenced above).

Based on observations, interviews and record review, the facility failed to ensure the resident environment remained as free from accident hazards as possible in the main dining room, and that each resident received adequate supervision and assistance devices to prevent accidents for the following residents: Two residents (#5 and #8) of five residents at risk for falling; and one resident (#22) who wandered with exit seeking behavior. Specifically, the facility: -Failed to ensure resident #5 had adequate supervision on the night. She suffered a fall and sustained a fractured hip. -Failed to ensure resident #8 had a functioning low bed in good repair and adequate supervision. The resident fell from bed and sustained a laceration which required sutures. -Failed to ensure resident #22 had adequate supervision and had consistently functioning wander alert device to prevent elopement. -Failed to ensure residents did not have access to a coffee brewing and hot water dispenser in the main dining room which dispensed hot liquids at temperatures that exceed acceptable, safe levels. The findings include: I. Falls A. Resident #5 1. Resident Status Resident #5, age [AGE] years, was admitted to the facility on [DATE]. Pertinent diagnoses, per the face sheet, included Alzheimer's disease, history of falling, type II diabetes, and chronic kidney disease. The resident's payer source, per the face sheet, was hospice. The 12/1/15 significant change minimum data set (MDS) comprehensive assessment revealed: -Cognition/Behavior: The resident had severe cognitive impairment as evidenced by brief interview for mental status score of 3 of 15. The resident had impaired vision and used corrective lenses. The resident did not exhibit delirium, psychosis, behaviors impacting the self or others, rejection of care or wandering during the MDS observation period. The resident was taking antipsychotic and antidepressant medications on each day of the assessment evaluation period. -Function: The resident was totally dependent on two staff for bed mobility. The resident required extensive assistance from two staff for transfers, dressing and toilet use. The resident was totally dependent on one staff for locomotion on and off the unit and bathing. Extensive assistance from one staff was required for eating and personal hygiene. The resident used a wheelchair for mobility. The resident was not steady and was only able to stabilize with human assistance then moving from a seated to standing position, moving on and off the toilet, and with surface to surface transfers. The resident had functional range of motion limitations to the bilateral upper extremities and to one lower extremity. The resident had not had any falls since the last comprehensive assessment. Fall risk evaluations completed on 1/11/16 and 12/1/15 showed the resident was at moderate risk for falls with scores of 12 and 14 respectively. The resident had been considered at high risk for falls on 9/23/15 and 7/21/15 with scores of 17 and 23 respectively. The fall care plan, last updated 1/11/16, stated the resident had the potential for falls related to poor safety awareness. The goal was the resident would not experience injury from falls through the next observation period. Pertinent fall prevention approaches included: -Attempt to provide attention to resident as she is self seeking, reinforce positive behaviors and or redirect to a known activity of interest - i.e., - baby dolls -Call light within reach at all times when in room with frequent reminders to use prior to getting up. -Lip mattress to bed -Low bed with mat -Self releasing seat belt to assist with positioning 2. Falls with injuries - Facility failures A review of the clinical record revealed the resident was at risk for falls. The resident experienced falls on 1/11/16 and 1/19/16; however, no new interventions to keep the resident safe were identified and integrated into the resident's plan of care. The failure to thoroughly investigate the resident's falls, implement new interventions and provide the resident adequate supervision contributed a fall with hip fracture 2/6/16 in the private dining room. Review of staffing logs for 2/6/16 revealed the facility was short staffed the evening when the resident fell . Review of Nurse's Notes revealed: On 1/11/16 at 2:40 a.m., a nurse's note stated the resident was found resident on the fall mat in a supine position by an agency certified nurse aide (CNA). The resident had a bump to the left forehead with no redness, discoloration or bruising. The resident denied needing to go to the bathroom. The resident denied pain, but Tylenol was given due to the bump on the forehead. No change in range of motion to the extremities was noted. On 1/11/16 at 2:47 a.m., a nurse's note stated that the hospice nurse practitioner was notified of the resident's fall. The staff was directed to follow the 72 hours neurochecks protocol and to monitor vital signs. Ice was applied to the forehead, as needed, for pain. On 1/11/16 at 6:00 a.m., a nurse's note stated the family was notified of the resident's fall. On 1/19/16 at 1:13 a.m., a nurse's note indicated a CNA found the resident on the floor beside her bed at 10:00 p.m. The resident experienced a hematoma to the left knee and a re-opening to the scab on the left elbow. The hospice nurse was notified and the plan was to notify family on the day shift. On 2/7/16 at 6:07 a.m., nurse's note, documented by the nurse on the overnight shift beginning 2/6/16, stated the following: -2/6/16 at 10:45 p.m., During change of shift nursing report, Registered Nurse(RN)/Agency nurse reported the resident was found on the floor laying to her left side in the private dining room at around 9:30 p.m. The resident was awake, verbally responsive and noted resident with a bump to left back side of the head without any skin breakdown or discoloration, left arm skin tear and left elbow skin tear. Per the RN/Agency nurse, resident was complained of left hip pain while being transferred to her bed. - 2/6/16 at 11:15 p.m., resident was assessed by two licensed practical nurses (LPNs). The resident was awake, alert, verbally responsive, oriented times one to two forgetfulness. The resident had a bump to left back side of the head without any skin breakdown or discoloration. The left lateral arm had abrasion. The left elbow had a skin tear measuring 1cm x 2cm, the left hip was bruised with some swelling noted to left hip area. The resident was guarding the left hip and was unable to move left lower extremity. The resident was moaning with facial grimacing. The resident was asked if she is in pain and what type of pain. The resident stated Yes, I'm hurting. Oh, I don't know. The resident was unable to describe the type of pain. The resident was asked where the pain was and stated My leg. (Rubbing her left lower extremity) The resident was asked if she could describe the level of pain from 0-10 and stated I don't know. Vital signs were: blood pressure 116/62; Pulse 68; Respirations 19. -2/6/16 at 11:25 p.m., Tylenol 650 mg was given for pain.-2/6/16 at 11:40 p.m., the nurse practitioner was called and notified of the fall. -2/6/16 at 11:58 p.m., the provider called back and was informed that the resident was found on the floor laying to her left side in the private dining room at around 9:30 p.m., by 3-11 shift Nurses/CNA. The provider was informed of the fall and the information contained in the note at 11:15 p.m.-2/7/16 at 12:25 a.m., the Tylenol given at 11:25 p.m. (2/6/16), was documented to be effective because the resident was sleeping. -2/7/16 at 12:40 a.m., the: X-ray technician arrived at resident ' s bedside. Staff assisted with the X-rays. The technician left at 1:06 a.m. -2/7/16 at 2:58 a.m., the provider was informed the X-ray result showed a fractured left hip. The provider ordered Norco 5/325 one tablet by mouth every four hours as needed for pain. Norco was given from the emergency kit.-2/7/16 at 3:40 a.m., the provider called back and ordered the resident to remain on bed rest until further notice. A CT scan of the hip was ordered. The plan was to discuss the plan of care with the family and the other providers. -2/7/16 at 3:45 a.m. the family was notified of the resident's hip fracture. Information regarding the plan of care and the resident's status from previous notes was conveyed.-2/7/16 at 5:20 a.m., the resident was in bed sleeping. No acute pain or distress noted. The resident was easily awakened to verbal and tactile stimuli. The resident was offered fluids as tolerated. The resident was assisted with activities of daily living by two staff. -2/7/16 at 6:40 a.m., the incoming shift nurse was notified of the resident's current condition, current orders, and made aware the resident had an order for [REDACTED]. Private Dining Room observations revealed: On 2/17/16 at 7:30 a.m., observation of the private dining room revealed it was visible from the lobby of the building. The private dining room was not visible from the sub-acute unit nurse's station, although staff in the hall of the sub-acute nurse's station could see someone enter the private dining room. The private dining room was not visible from the long term care hall. Staff from the long term care unit would have to leave the unit and pass by all of the rooms on the 300 hall, pass by the activity room, a pass by hallway to the kitchen and staff offices in order to reach a place where the private dining room was visible. A resident in the area of the private dining room would not be readily monitored by staff except during meal service and regular business hours by office staff. b. Facility failure to investigate the resident's falls, implement new interventions and provide resident #5 adequate supervision (1) Record review Fall investigations: The 1/11/16 fall investigation/incident report stated the plan to keep the resident safe included offering the resident fluids at frequent intervals, offering the resident to toilet at frequent intervals and to provide frequent visual monitoring of the resident. The fall investigation did not identify if the resident was wet/soiled at the time of the fall, if the lipped mattress was in place on the bed, if the resident expressed hunger, thirst, boredom, loneliness, or pain. Staff caring for the resident was not interviewed in order to identify pertinent concerns that may have contributed to a fall. The 1/19/16 fall investigation/incident report did not suggest any new approaches for keeping the resident safe. The fall investigation did not identify if the resident was wet/soiled at the time of the fall, if the lipped mattress was in place on the bed, if the resident expressed hunger, thirst, boredom, loneliness, or pain. Staff caring for the resident was not interviewed in order to identify pertinent concerns that may have contributed to a fall. The 2/6/16 fall investigation was incomplete. The fall investigation consisted of a summary by the agency RN that, in pertinent part stated, Notified by another resident that a patient was on the floor. Found her lying on L side .Has sm(all) skin tear inferior forearm was well as L writs. C/o pain, it hurts but unable to determine if any change from baseline immediately. Used folded draw sheet with 4 staff to lift pt (patient) to w/c (wheelchair). Also has sm(all) bump to superior occipital. Care plan: See above; although updated 1/11/16, review of the plan of care revealed that no new interventions for fall prevention/injury minimization had been initiated since 7/22/15. (2) Staff Interviews Staff interviews confirmed the resident had a history of [REDACTED]. Falls were not thoroughly investigated and new interventions to reduce fall risk were not identified, care planned and implemented. The resident, who had previous unwitnessed falls, had not been visualized by direct care staff for at least two hours prior to the fall with hip fracture on 2/6/16, when the building was short of one nurse and one CNA on the evening shift. (1) On 2/17/16 at 9:45 a.m., staff member #19, who requested anonymity, stated s/he was concerned about low staff levels in the building. According to the staff member, the lack of staffing resulted in inadequate monitoring of residents at risk for falls. The staff member cited resident #5's recent fall as an example of how inadequate staffing impacted resident safety. Per the staff member, the resident was found on the floor in the private dining room at 9:30 p.m. No one knew how long the resident had been there on the floor. (2) On 2/19/16 at 3:16 pm., LPN #8, who reported caring for resident #5, stated the resident had falls. The LPN stated the resident was known to have falls from bed and from the wheelchair. The LPN stated the resident had slowed down on the falls for awhile but then began experiencing more falls. The LPN stated the resident could move slowly around the using her feet to propel the wheelchair. She said the resident was known to stay up later and to be restless. The LPN stated she was not working on the night the resident fell and broke her hip. According to the LPN, the resident passed away about week after she broke her hip. (3) On 2/22/16 at 3:08 p.m., RN #4 stated she had heard the resident broke her hip in a fall in the dining room. The RN stated she was not working on the night of the fall. The RN acknowledged the resident passed away after the fall. (4) On 2/22/16 at 3:45 p.m., CNA #7, who worked on 2/6/16, the evening the resident fell , stated: -The resident was known to fall and had fallen at the facility in past. The CNA said she had not been told to watch the resident more closely after recent falls. She explained the resident was able to slowly propel around the facility in her wheelchair using her feet, but had been doing this less often in the last few months. -The CNA reported not seeing the resident after completion of the evening meal until the resident was found on the floor in the private dining room. According to the CNA, after supper many residents want to go to bed and she was busy with evening cares until she was notified of the resident's fall. -The CNA stated it was not possible to see the private dining room from the long term care unit, so anyone in the area of the dining room after the evening meal would not be readily visible to staff. The CNA stated it was important to keep the residents with falls in the TV room on the unit so nursing could monitor them. -The CNA stated that they were working short staffed on the evening of 2/6/16. The CNA reported there were two nurses instead of three nurses and there were times when there were fewer than four CNAs during the evening shift. The CNA reported working short staffed a lot in recent months. -The CNA stated that a nurse from agency was the one notified of the resident's fall. The resident was moved to her wheelchair, then to her bed, and remained at the facility for an x-ray which showed a hip fracture. The CNA stated that after the hip fracture, the resident stopped eating, drinking and passed away. (5) On 2/23/16 at 8:00 a.m., CNA #13, who worked the evening of 2/16/16 and who was assigned to the resident's hall, stated: -She arrived to work the evening shift at around 7:00 p.m. At that time, there were two nurses instead of three and three CNAs instead of four on duty. The CNA stated she was relieving another CNA who left at 7:00 p.m. The CNA leaving at 7:00 p.m. had been assigned to the hall where resident #5 lived. The CNA stated a fourth CNA arrived to help on the unit at around 8:00 p.m. According to the CNA, it was very hard to monitor the whereabouts of mobile residents when the unit was short staffed. -The CNA stated she did not see the resident prior to being notified of the resident being found on the floor around 9:30 p.m. The CNA said the resident was found on the floor in the private dining room by the CNA from the sub-acute unit. The RN from the agency, who was assigned to the hall where the resident had resided, assessed the resident post-fall. The resident was moved from the floor to her wheelchair and from the wheelchair to the bed. The CNA stated the resident broke her hip in the fall on 2/6/16 and had passed away on 2/16/16. (6) On 2/23/16 at 6:05 a.m., LPN #2, who cared for the resident on 2/6/16, stated: -The resident fell sometime between 9:00 p.m. and 9:30 p.m. and was found on the floor in the private dining room. The LPN stated he knew the resident's leg was broken because the left leg was shorter. The fracture was confirmed with a stat (immediate) x-ray. The LPN stated the resident was usually in bed during the night shift. The LPN said the resident had a history of [REDACTED]. (7) On 2/23/16 at 4:25 p.m., an interview with the interim director of nursing (IDON) revealed: -The IDON reported the resident had two falls in January 2016 before the fall on 2/6/16. Fall investigations/incident reports were in process for the January falls. -The IDON stated the resident was mobile in her wheelchair, and could move slowly around the facility using her feet. -The IDON stated the resident's falls on 1/11/16 and 1/19/16 were investigated; however, she confirmed the previous falls were not analyzed to identify causation or contributing factors with the goal of implementing interventions to minimize future falls. -The IDON acknowledged the 1/11/16 fall investigation showed frequent visual monitoring as an approach for keeping the resident safe after the 1/11/16 fall. The IDON acknowledged the plan to furnish frequent visual monitoring of the resident was not translated into a care plan for the resident. -The IDON acknowledged the fall investigations did not gather information from witnesses or the last staff person to see the resident prior to the fall and that pertinent information in investigating causation and reduce fall risk, like the resident being wet/soiled from incontinence, resident footwear, resident needs at the time of the fall like hunger, loneliness, boredom, or proper function of critical equipment were not investigated related to falls. The IDON stated her role in conducting a fall investigation was to ensure it was completed by the nurse responsible for the resident at the time of the falls and to sign off on it. -The IDON stated falls were not discussed with the interdisciplinary team (IDT) or a fall committee as the facility did not have a fall committee to work on strategies to reduce resident falls. The IDON was unaware of any quality assurance (QA) processes in place to reduce resident falls with injury. -The IDON acknowledged that the staffing schedule regularly did not have all planned positions filled and agreed residents that required supervision for fall prevention could not be adequately monitored with insufficient staff. -The IDON stated she was new to the position and did not have much experience in long term care. The IDON stated she started at the facility as a unit manager and was moved up to the assistant director of nursing (ADON) position in a few weeks. The IDON reported that after a couple of weeks as the ADON she became the IDON. 3. Staffing Schedule A review of the 1/11/16 staffing schedule showed all planned staff was present on the shift when the resident fell . A review of the 1/19/16 staffing scheduled revealed the evening shift was short two of four planned CNAs. Three of three nurses were present. The night shift had one of the two CNAs from the evening shift staying over to work a double shift. The night shift was short one nurse and one CNA. A review of the 2/6/16 staffing schedule on the evening shift when the resident fell revealed two of three planned nurses were present for the shift. Three of four planned CNAs were present for evening shift from 2:30 p.m. and until 8:00 p.m., when a fourth CNA arrived. The night shift on 2/6/16 was short one CNA. B. Resident #8 1. Resident Status Resident #8, age [AGE] years, was admitted to the facility on [DATE]. Diagnoses, per the face sheet, included [DIAGNOSES REDACTED] and hemiparesis following cerebral infarction affecting the left non-dominant side, history of falling, and unspecified heart failure. The12/10/15 admission minimum data set (MDS) comprehensive assessment revealed: -Cognition/Behavior: The resident was had moderate cognitive impairment was evidenced by a brief interview for mental status score of eight of 15. The resident did not exhibit delirium, psychosis, behaviors impacting the self or others, rejection of care or wandering during the MDS observation period. -Function: The resident required extensive assistance from two staff for bed mobility, transfers, toileting and dressing. Extensive assistance from one staff was required for locomotion on the unit and personal hygiene. The resident was totally dependent on one staff for bathing and required set-up and supervision with eating. The resident was not steady and was only able to stabilize with human assistance then moving from a seated to standing position, moving on and off the toilet, and with surface to surface transfers. The resident was frequently incontinent of bladder and always continent of bowel. Fall risk assessments completed on 12/3/15, 1/1/16 and 2/23/16 showed the resident was at-risk for falls. The 12/3 and 2/23 assessments showed the resident was at high risk for falls with scores of 22 and 16 respectively. The 1/1/16 assessment showed the resident was moderate risk for falls with a score of 12. The 12/14/15 fall care plan stated the resident was at risk for falls related to the late effects of a stroke and generalized weakness. The goal was for the resident to be free from falls and/or injuries through the next review date. The approaches were: -Assist with transfers - Call light in reach -Notify physician and family of any falls -Remind to request staff assistance for all transfers 2. Observation On 2/14/16 at 4:45 a.m., resident #8 was observed sleeping in a tilt-in-space wheelchair in the living room on the long term care unit. The resident was one of four individuals sleeping in a recliner or in a wheelchair in the common area. LPN #1 stated the residents sleeping in the common area were the residents that flopped around all night falling from bed and were sleeping in the living room so staff could keep an eye on them. The LPN stated the facility was short one CNA on the night shift on 2/14/16 and had three CNAs total for 77 residents. There were two CNAs assigned to the long term care hall with 65 residents. On 2/23/16 at 1:20 p.m., resident #8 was observed in her bed. The resident's bed was not in the lowest position. There was approximately one foot of height before the resident's bed was in the lowest position. The resident had a bandage to the right forehead over her eyebrow. The resident had a blackened right eye and bandages were in place on the resident's right and left shin. The resident's daughter, who was a RN, exposed the skin below the bandage on the left shin. The area beneath the bandage was a half-dollar sized oblong area of black/dark purple skin that looked like a blood blister. The resident was in semi-Fowler's position (head of the bed elevated) in the bed. On 2/23/16 at 1:25 p.m., an attempt was made to lower the bed to its lowest position. As the bed was lowered, the mattress began to become uneven; the mattress was higher on the wall side of the bed and was lower on the right/exit side of the bed. The bed was raised back up until the mattress again was level. (A note on the maintenance log documented the resident's bed had a left (wall side) bed rail that was broken and needed to be fixed but there was no note about the inability to lower the resident's bed without creating a tilt in the mattress.) 3. Family Interview On 2/23/16 at 1:20 p.m., an interview with the resident's daughter revealed the resident fell from bed. The daughter stated the resident was sent out to the emergency department on 2/22/16 because of a fall. The daughter stated she had no idea how her mother, who did not move on her own, fell from bed. The daughter stated the resident had sustained a skin tear on the forehead that required stitches and that her shins had all the skin scraped off. The daughter stated that her mother may have attempted to exit the bed for toileting. She said the resident was continent, but needed a bed pan. She said staff did not timely respond to call lights and ignored her mother, because her room was at the end of the hall. 4. Record Review - Fall with injuries A 2/23/16 at 12:02 a.m., nursing note read the resident had no concerns when checked on 2/22/16 at 7:00 p.m. for dinner and at 7:20 p.m. On 2/22/16 at 7:40 p.m., the resident was heard screaming and was found face down on the floor. Blood was noted on the floor. The facility called 911 and the resident was sent to the hospital. The IDON, medical provider, and family were notified of the fall. The hospital informed the facility the resident had received sutures to the forehead, skin glue to the bilateral shins and was being sent back to the facility because the CT scan was negative. A 2/23/16 at 11:20 a.m., nursing note read an LPN entered the resident's room at 7:15 a.m. to administer medications. The resident was found half out of bed. The resident's legs were hanging off the bed to the left from knees down. The resident's torso was leaning to the right towards edge of bed, right arm dangling on floor. She could not express how she came to that position. The resident was alert, anxious and confused. The resident was assisted to sit upright in the bed. Fall precautions were in place with bed in a lowered position and a fall mat in place. 5. Staff Interviews On 2/23/16 at 10:08 a.m., the therapy director (TD) stated therapy did occasionally consult on falls. The TD stated there had been an unusual fall the previous night where a resident that was immobile had somehow managed to fall from bed and become injured. On 2/23/16 at 1:35 p.m., an interview with CNAs #10 and #3 revealed the resident's bed was not working properly. CNA #10 confirmed the resident's bed/mattress became uneven when being lowered to the lowest position because of a disused partial side rail. CNA #10 pointed out a partial side rail on the upper half of the wall-side of the bed. CNA #10 stated a work order had been turned in related to the side rail on 2/19/16. According to CNA #10, the director of maintenance (DM) refused to raise the side rail because the rails were not allowed in the facility. The DM declined to remove the rail as well. On 2/23/16 at 1:45 p.m., an interview with the DM revealed that he had received a work order related to the side rail on the resident's bed. The DM stated he did not raise or remove the rail. An observation with the DM of the resident's bed being lowered again showed the mattress becoming uneven with the wall side of the mattress lifting and tilting the mattress toward the exit side of the bed. The DM stated he was not aware the lowered side rail created a problem when the bed was placed in the lowest position for resident safety. II. Wandering Resident #22 1. Resident #22, age [AGE] years, was admitted to the facility on [DATE]. Diagnoses, per the medication administration record (MAR) included hypertension, insomnia, and anxiety. An admission note dated 2/18/16 at 1:54 p.m., stated that the resident's primary [DIAGNOSES REDACTED]. A 2/18/16 social service note stated the resident had a brief interview for mental status score of 12 of 15 which indicated moderate cognitive impairment. A [DIAGNOSES REDACTED]. Due to the resident's recent admission status, the minimum data set comprehensive assessment had not been completed for the resident. 2. Observations and Interviews a. 2/18/16 On 2/18/16 at 4:00 p.m., resident #22 was observed walking up and down the long term care halls. The resident was headed towards an exit. No wanderguard was observed on the resident. The admissions director was observed to redirect the resident toward the living room in the long term care unit. The resident was observed to be walking quickly and moving up and down the various halls in the unit. The resident was observed to continue to pace the hallways and to be re-directed from the exits when observed again at 4:45 p.m. On 2/18/16 at 4:50 p.m., an interview with visitor #1, who was a regular visitor of the resident's roommate, revealed that since his admission, resident #22 had opened the door in the sun room causing an alarm to sound and caused multiple alarms to sound on the unit due to his attempts to leave the building. The visitor stated she had observed nursing staff chasing after the resident as the alarms sounded. On 2/18/16 at approximately 5:30 p.m., the facility's clinical nurse consultant (CNC) and the regional vice president (RVP) were informed of concerns regarding the resident pacing and exit seeking. They responded by saying they were told the resident was not exit seeking by the admissions director. They then stated they would put monitoring in place to keep the resident safe. Details of the safety plan were not specified at that time. b. 2/19/16 On 2/19/16 at 11:15 a.m., the resident was observed walking at a quick pace throughout the long term care unit. The resident was heading up and down the halls. c. 2/20 - 2/21/16 On 2/24/16 at 10:50 a.m., an interview with visitor #2, a family member who regularly visited a family member residing in the facility, revealed she had observed the resident out of the facility over the weekend (2/20 - 2/21/16). The visitor, who came regularly to the facility to visit their family member, said she was leaving the facility after visiting her family member and saw resident #22 walking down the road by the church. (Per Google maps, the walk time from the facility to the church was six minutes with a distance of 0.3 miles). The visitor stated she turned around, drove back to the facility and informed the staff resident #22 had wandered off. The visitor stated she followed the nurses that went to retrieve the resident in her vehicle. The visitor stated the resident had made it around the corner to the next road by the time staff reached him and said it was lucky she saw the resident because he was a fast walker. The visitor acknowledged the undeveloped terrain, the proximity to the interstate and wildlife as hazards the resident could have encountered while out of the building. On 2/24/16 at 9:00 a.m., an interview with staff member #19 confirmed the resident had left the facility over the weekend. According to the staff member, another resident's family member noticed the resident walking down the road and informed the facility in person of the resident's absence. The staff member expressed concern that if not for the family member, the resident could have come to harm. The staff member stated that at the time the resident left, the resident had been on 15 minute checks, which were ineffective for a resident that was very mobile. c. 2/23/16 On 2/23/16 at approximately 6:20 p.m., the resident was observed to exit the front door of the building. No alarm was heard to sound. No staff member was with the resident. The resident followed the crushed gravel path to the left of the front door to the gate and to the sitting area around the front of the building. The area was dark. No staff was present with the resident. The resident was observed to open the gate and head into the dark, fenced area. On 2/23/16 at 6:25 p.m., the nursing home administrator (NHA) and CNA #10 were summoned to the resident's location outside the facility. The NHA and the CNA confirmed the resident had exited the building without sounding an alarm and without staff knowledge/presence. Observation of the lobby revealed there were nurses at their medication carts, CN

Based on observations, record review, and staff interviews, the facility failed to ensure two of 22 sample residents (#1 and #5) received, and the facility provided, the necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, the facility: -failed to assess, monitor, and manage pain for resident #5 contributing to the resident experiencing unrelieved pain during movement/cares/positioning. -failed to communicate sufficiently with the [MEDICAL TREATMENT] center for resident #1 to ensure the provision of care and services ordered and expected were being implemented. I. Resident #5 Resident #5, age [AGE] years, was admitted to the facility on [DATE]. Pertinent diagnoses, per the face sheet, included [MEDICAL CONDITION], history of falling, type II diabetes, and [MEDICAL CONDITION]. The resident's payer source, per the face sheet, was hospice. The resident expired at the facility [DATE]. A. Resident Status The [DATE] significant change minimum data set (MDS) comprehensive assessment revealed: -Cognitive/Behavior: The resident had severe cognitive impairment as evidenced by brief interview for mental status score of three of 15. The resident had impaired vision and used corrective lenses. The resident did not exhibit [MEDICAL CONDITIONS], behaviors impacting the self or others, rejection of care or wandering during the MDS observation period. -Function: The resident was totally dependent on two staff for bed mobility. The resident required extensive assistance from two staff for transfers, dressing and toilet use. The resident was totally dependent on one staff for locomotion on and off the unit and bathing. Extensive assistance from one staff was required for eating and personal hygiene. -Pain: The resident did not experience pain impacting sleep or daily routine during the assessment observation period. A pain care plan initiated on [DATE] stated the resident had the potential for pain related to [MEDICAL CONDITION]. The goal was for the resident to verbalize or show signs of adequate pain control with interventions. Approached to the pain control included: -Administer pain medications as ordered and document effectiveness. -Attempt non-pharmacological interventions like repositioning (which created pain after the [MEDICAL CONDITION]), massage, diversional activities and toileting (which also caused pain after the [MEDICAL CONDITION]) -Pain assessment each shift and as needed. Review of the resident's clinical record revealed the resident fell ,[DATE], ,[DATE], and [DATE]. The resident's fall [DATE] resulted in a [MEDICAL CONDITION]. (Cross refer to F323 for further details) B. Record Review A review of the clinical record revealed the resident experienced a two hour delay in relieving the pain from a [MEDICAL CONDITION] on [DATE]. Although the resident experienced pain with movement and cares, the resident was not medicated 30 minutes prior to movement/cares as intended by the provider who ordered [MEDICATION NAME] sulfate on [DATE]. The resident experienced unrelieved severe pain based on comparison of when medications were given and when pain was reported on the each shift pain assessment. 1. Nurse's Notes A [DATE] at 6:07 a.m., nurse's note documented the following: -[DATE] at 10:45 p.m., the resident was found on the floor of the private dining room around 9:30 p.m. The resident complained of left hip pain while being transferred to her bed. - [DATE] at 11:15 p.m., resident was assessed by two LPNs. The left hip was bruised with some swelling noted to left hip area. The resident was guarding the left hip and was unable to move left lower extremity. The resident was moaning with facial grimacing. The resident was asked if she is in pain and what type of pain. The resident stated Yes, I'm hurting. Oh, I don't know. The resident was unable to describe the type of pain. The resident was asked where the pain was and stated My leg. (Rubbing her left lower extremity) The resident was asked if she could describe the level of pain from ,[DATE] and stated I don't know. -[DATE] at 11:25 p.m., Tylenol 650 mg was given for pain. (This represented a two hour delay in pain relief for a [MEDICAL CONDITION].)-[DATE] at 11:58 p.m., the provider called back and was informed that the resident was found on the floor laying to her left side in the private dining room at around 9:30 p.m., by ,[DATE] shift Nurses/CNA. The provider was informed of the fall and the information contained in the note at 11:15 p.m.-[DATE] at 12:25 a.m., the Tylenol given at 11:25 p.m., was documented to be effective because the resident was sleeping. -[DATE] at 12:40 a.m., the: X-ray technician arrived at resident ' s bedside. Staff assisted with the X-rays. The technician left at 1:06 a.m. -[DATE] at 2:58 a.m., the provider was informed the X-ray result showed a fractured left hip. The provider ordered [MEDICATION NAME] ,[DATE] one tablet by mouth every four hours as needed for pain. [MEDICATION NAME] was given from the emergency kit. (This was not documented in the MAR.)-[DATE] at 3:40 a.m., the provider called back and ordered the resident to remain on bed rest until further notice. -[DATE] at 3:45 a.m. the family was notified of the resident's [MEDICAL CONDITION]. -[DATE] at 5:20 a.m., the resident was in bed sleeping. No acute pain or distress noted. -[DATE] at 6:40 a.m., the incoming shift nurse was notified of the residents current condition, current orders. A [DATE] at 12:11 a.m., nurse's note stated the, Resident cries during repositioning. A [DATE] at 10:25 p.m., nurse's note stated, Resident in bed, denies any pain/discomfort when asked, but screams during repositioning. [MEDICATION NAME] ([MEDICATION NAME] sulfate) given as ordered. A [DATE] at 4:45 a.m., nurse's note stated that the resident denied pain but grimaces and cries out when the left leg is touched or moved. A [DATE] at 9:00 p.m., nurse's note stated the resident had increased pain noted during incontinence cares. The hospice provided orders to place a Foley catheter for resident comfort. 2. Medication Administration Record (MAR) The February 2016 MAR revealed: -an order for [REDACTED]. Tylenol was given on [DATE] at 5:53 p.m., only. -On [DATE] an order for [REDACTED]. The MAR showed the [MEDICATION NAME] was given twice; once on [DATE] at 8:58 p.m., and once on [DATE] at 2:47 a.m. -On [DATE] an order for [REDACTED]. The resident received six doses of [MEDICATION NAME] sulfate. The [MEDICATION NAME] was given on ,[DATE] at 9:26 p.m., ,[DATE] at 4:32 a.m., ,[DATE] at 9:30 a.m., ,[DATE] at 2:33 a.m., ,[DATE] at 3:04 p.m. and ,[DATE] at 7:53 p.m. -The per shift pain assessment on the MAR stated, pain scale: Wong-Baker (,[DATE]) Assess resident for pain each shift (+) pain (-) no pain. The MAR provided a place where once a shift resident pain levels could be documented. Pertinent resident's pain levels were recorded as: -- + on the ,[DATE] overnight shift --5 (hurts worst on the Wong-Baker faces pain scale) on ,[DATE] day shift --+ on the ,[DATE] evening shift -- 4 (it hurts a whole lot on the Wong-Baker faces pain scale) on the ,[DATE] day shift -- + on the ,[DATE] evening shift --+ on the ,[DATE] evening shift --5 on the ,[DATE] day shift --5 on the ,[DATE] day shift --2 (hurts a little more on the Wong-Baker faces pain scale) on the ,[DATE] day shift Comparison of reported pain and pain medication administration revealed the resident had unrelieved severe pain on the day shift on ,[DATE], ,[DATE] and [DATE]. Unrelieved pain was also identified on the evening shift on ,[DATE] and the day shift on [DATE]. 3. Narcotic Sheets Narcotic sheets, requested from the interim director of nurses (IDON) on [DATE] at 10:00 a.m. were not furnished for the [MEDICATION NAME] sulfate. The narcotic sheets for the [MEDICATION NAME] ,[DATE] for the resident showed the resident received [MEDICATION NAME] as described on the ,[DATE] MAR and one dose of [MEDICATION NAME] ,[DATE] from the e-kit (emergency medicine storage kit) on [DATE] at 11:25 p.m. 4. See also the resident's care plan for pain above; the directive to staff to notify the nurse 30 minutes prior 30 minutes for clean up or position change was not documented on the plan. C. Staff Interviews Interviews with facility staff confirmed the facility failed to adequately assess and timely and adequately address the resident's pain following her fall with [MEDICAL CONDITION]. Pain medication was not given as ordered. The resident had a two hour delay in pain relief immediately after the fall. And the resident, who experienced pain with movement/care/positioning, failed to receive pain medication prior to movement/care/positioning as ordered. This failure resulted in the resident experiencing unrelieved, severe pain with cares. (1) On [DATE] at 3:45 p.m., an interview with certified nurse aide (CNA) #7 revealed the CNA was called to assist when the resident was found on the floor of the private dining room on [DATE] between 9:00 and 9:30 p.m. The CNA stated the resident was in pain. The resident yelled and screamed with any movement. The CNA denied seeing the resident being offered pain medicine prior to moving the resident from the floor. The CNA reported an agency nurse, another CNA, and licensed practical nurse (LPN) #2 moved the resident from the floor to her wheelchair using a sheet. The resident was then moved from the wheelchair to her bed. The CNA stated the resident cried out in pain with all movement. The CNA stated as they were undressing the resident after placement in bed, she observed purple bruising to the left hip. The CNA stated she was required to assist the resident with positioning for the x-ray later that night. The CNA reported, again, the resident cried out in pain at being moved. The CNA reported that in the days after the fall, the resident continued to express pain and discomfort with position changes and with movement during cares. The CNA was not aware of the pain relief measures in place to address the resident's pain, except the resident had a catheter placed so staff did not have to move her as much. The CNA reported notifying nurses of the resident's pain. (2) On [DATE] at 6:05 a.m., an interview with LPN #2, who worked the night shift caring for the resident on [DATE] and who reported usually providing care to the resident prior to her passing on [DATE], stated that at the time of her fall the resident was on hospice. The LPN said she worked the night shift on the evening the resident fell and fractured her hip. The resident was not sent out to the hospital for a surgical repair of the [MEDICAL CONDITION]; rather, she remained at the facility on bed rest. The LPN provided pain assessment and monitoring for the resident on scheduled shifts after the resident's fall. The LPN reported at the time of the fall, the resident only had an order for [REDACTED]. The LPN stated the nurse practitioner had stated she preferred to wait until the x-ray results were in before authorizing narcotic pain medication for the resident. The LPN stated he knew the resident was in pain after the fall because of her crying, facial grimacing, and guarding her left leg. The LPN reported that Tylenol was a medication for mild pain and was not meant for severe pain. The LPN stated he gave the resident Tylenol and thought it was effective because the resident appeared to be sleeping. However, he said the resident experienced pain and guarded the hip during the x-ray. The LPN stated as needed [MEDICATION NAME] (narcotic pain medication for moderate pain) ,[DATE] mg was ordered for the resident on [DATE] and the hospice nurse ordered [MEDICATION NAME] sulfate on [DATE]. However, he confirmed the resident continued to complain of pain with movement. (3) On [DATE] at 8:00 a.m., an interview with CNA #13 revealed she was working the night the resident fell and assisted with the resident's cares. The CNA stated the resident said she was in pain even before she was moved. The resident cried out when moved from the floor to the wheelchair. The CNA stated she did not observe the resident to be offered pain medication prior to moving from the floor. The CNA stated the resident cried out again when being moved from the wheelchair to the bed. (4) On [DATE] at 11:09 a.m., an interview with CNA #10, who cared for the resident during scheduled shifts after the [MEDICAL CONDITION], revealed the resident required total assistance with cares after the fracture. Two or more staff was needed to check and change her incontinence brief, provide perineal cares, and reposition the resident to prevent skin breakdown. The CNA stated that after the fall, every time staff moved the resident during cares, she screamed in pain. The CNA stated even touching the resident seemed to cause pain. According to the CNA, the resident refused turning related to the pain upon movement. The CNA stated the resident was not able to state she was in pain or to request pain medications. She said staff could tell the resident was in pain due to her facial expressions and calling out. The CNA stated the CNAs informed the nurses of the resident's pain and said a catheter was placed to help minimize the need to move the resident. The CNA said she was not informed to notify the nurse 30 minutes prior to providing cares so that pain medication could be administered. (5) On [DATE] at 10:00 a.m., the IDON reviewed resident #5's record and stated that even though the resident had experienced a fracture, staff had not conducted a new comprehensive pain assessment for the resident. The resident's last comprehensive pain assessment was completed on [DATE]. The IDON stated that after the non-repaired [MEDICAL CONDITION] [DATE], the resident had received no doses of Tylenol according to the medication administration record (MAR). The IDON stated the MAR showed the resident's first pain relief was [MEDICATION NAME] ,[DATE], offered on [DATE] at 10:58 p.m. for the fall that occurred on [DATE] at between 9:00 and 9:30 p.m. The IDON confirmed the resident had an order for [REDACTED]. She confirmed the order for the [MEDICATION NAME] read it was to be given as needed for pain and 30 minutes prior to moving the resident for clean up or position changes. Her interview revealed the resident was not medicated prior to position changes, as ordered. Specifically, the IDON said the [MEDICATION NAME] was given a total of six times, starting on [DATE]. No [MEDICATION NAME] was given on [DATE] or [DATE]. The IDON stated that if the staff was providing check and change and repositioning every two hours, the resident would be moved at least 12 times per day by staff. 2. Resident #1 Resident #1, a [AGE] year old female, was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. a. Resident Status The minimum data set ((MDS) dated [DATE] scored the brief interview of mental status (BIMS) at 15 out of 15, indicating the resident was cognitively intact. The resident needed the assistance of two people with bed mobility, transfers, dressing, bathing, and toilet use. The MDS identified the resident received [MEDICAL TREATMENT] services. Review of the resident's care plan, dated [DATE], included plans of care for [MEDICAL TREATMENT] ([DATE]) and altered nutritional status related to [MEDICAL TREATMENT] ([DATE]). -The care plan for [MEDICAL TREATMENT] included the interventions of labs, pre and post weights and pre and post blood pressure monitored at [MEDICAL TREATMENT] Center. The [MEDICAL TREATMENT] center was to provide the facility with results. -The care plan for altered nutritional status related to [MEDICAL TREATMENT] dated [DATE] included weigh weekly. Monitor labs, [MEDICAL TREATMENT] reports, and dry weights. The computerized physician's orders [REDACTED].>-weekly weights every Wednesday -[MEDICAL TREATMENT] weight monitoring b. Failure to ensure resident weights were monitored pre and post [MEDICAL TREATMENT] and weekly as ordered. Record review revealed the resident's record did not have any documentation or communication sheets with the [MEDICAL TREATMENT] center regarding the resident's status, including the resident's weights pre or post [MEDICAL TREATMENT]. Further review of the resident's record revealed no documentation of pre and post weights on the days the received [MEDICAL TREATMENT] (M/W/F) or weekly weight every Wednesday as ordered. b. Interviews On [DATE] at 10:00 a.m. the licensed practical nurse (LPN) #9 said the residents who are on [MEDICAL TREATMENT] have a folder and all the communication sheets are in the folder. The LPN also said the facility fills out the first part of the communication sheet, which includes vital signs and medications, and sends the entire folder, which includes prior communication sheets, to the [MEDICAL TREATMENT] center. When the resident returns from [MEDICAL TREATMENT], the [MEDICAL TREATMENT] center is expected to have completed the bottom part of the communication form which includes vital signs but not pre/post [MEDICAL TREATMENT] weights, although she said the [MEDICAL TREATMENT] center was the only entity that took resident weights. She did not indicate anyone had followed up on the lack of weights received from the [MEDICAL TREATMENT] center. The LPN also said she did not know what happened to the resident's older communication sheets and the folder. On [DATE] at 11:30 a.m. the [MEDICAL TREATMENT] center nurse explained the process and expectations of the facility and the [MEDICAL TREATMENT] center as follows: The facility is to send a form with the resident that includes the resident's vital signs and medications; the [MEDICAL TREATMENT] center completes the rest of the form, which by observation, did not include a place to document the resident's pre and post [MEDICAL TREATMENT] weights. The nurse said if there are any problems during [MEDICAL TREATMENT], the center calls the facility; however, the nurse said the facility does not always answer the phones, or sometimes it takes hours to get a call back from the facility to the [MEDICAL TREATMENT] center. On [DATE] at 6:05 a.m., LPN #2 stated morning shift was responsible for completing the [MEDICAL TREATMENT] communication sheets because resident #1 was generally sent out at 10:00 a.m. or 11:00 a.m. If a resident received [MEDICAL TREATMENT] at 5 a.m. or 6 a.m. the night LPN would usually get the resident's vitals, but the LPN did not indicate this included the resident's weight. On [DATE] at 11:50 a.m. the resident's physician stated the resident would sometimes refuse [MEDICAL TREATMENT], would become confused and staff would call and report the resident's increased confusion. The provider stated she directed the facility to send the resident to [MEDICAL TREATMENT] because the increased confusion was most likely from missing [MEDICAL TREATMENT]. On [DATE] at 3:00 p.m. the interim director of nursing (IDON) said the [MEDICAL TREATMENT] center was responsible for obtaining the pre/post [MEDICAL TREATMENT] weights and the facility should have entered the weights into the computer. The IDON did not indicate she was aware no resident weights were being received on the communication form or received from the [MEDICAL TREATMENT] center.

Based on family interviews, staff interviews and record review, the facility failed to provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one resident (#2). Specifically: The social service department failed to: Coordinate with the interdisciplinary team to identify, assess and care plan resident #2's mental health needs related to loss of independence and recent loss of a parent; failed to identify, communicate and arrange for discharge to a facility more able to meet the resident's unique psychosocial well-being needs; and failed to provide timely updates on the resident health status to interested family members. The social service department's failure to provide medically related social services contributed to a decline in the resident's psychosocial well-being, as evidenced by increased signs and symptoms of depression and care refusals which contributed to self-harm. The findings include: Cross reference to F319 Mental and Psychosocial Functioning for interviews and record review related to the resident's unaddressed decline in mental and psychosocial functioning resulting in care refusals which contributed to multiple and advanced stage pressure ulcers. I. Resident History and Admission Status A. Resident Prior to Admission Resident #2, age below 55, was admitted to the facility on [DATE] from a rehabilitation hospital. The face sheet showed the resident's [DIAGNOSES REDACTED]. Information provided by the rehabilitation hospital to the facility demonstrated the resident had history of advance stage wound to the sacrum (stage III). Additionally, the resident was known to have no movement of the lower extremities. Information provided by the rehabilitation hospital further showed the resident was living independently and working a job prior sustaining injuries that resulted in a traumatic brain injury (TBI) and paralysis of the lower extremities. In addition, the resident's mother had recently passed away. Information provided by the rehabilitation hospital to facility demonstrated the resident had a history of [REDACTED]. The resident was in a confusion state with severe amnesic symptoms related to the motor vehicle accident that resulted in paralysis and TBI. The resident did not know his exact age or how he came to be in the hospital. The resident had some understanding of his prior life, but did not recall details. The resident had been receiving psychiatric services at the rehabilitation hospital for management of psychotropic medications, memory deficits and blunted, flat affect. Recommendations included in the 10/20/15 psychiatry consultation that suggested augmenting the Risperdal (antipsychotic) with Abilify (antipsychotic) to see if it helped with a brighter mood and more interactive capacity. An 11/3/15 psychiatry consultation indicated switching from Risperdal to Abilify to see if it helps enliven him somewhat. At the rehabilitation hospital the resident had been participating in many therapies including occupational, recreational and physical. Notes furnished to the facility from the rehabilitation hospital did not show the resident to exhibit care refusal concerns. B. Resident Status on Admission - Cognitive/Behavior/Mental Health Review of the resident's 11/23/15 admission minimum data set (MDS) comprehensive assessment revealed: -The resident had unclear speech, usually understood others' communications and was usually understood by others. The resident had moderate cognitive impairment as evidenced by a brief interview for mental status score of 12 of 15. -The resident reported feeling down, depressed or hopeless half or more of the days in the past two weeks. The resident reported having trouble concentrating on things such as reading the newspaper or watching television half or more of the days in the past two weeks. -The resident did not exhibit behavioral symptoms impacting the self or others and did not exhibit signs and symptoms delirium or psychosis. The resident did not exhibit rejection of cares. -The resident required extensive assistance from two or more staff for bed mobility, transfers, dressing, and toilet use. Extensive assistance from one staff was required for locomotion on and off the unit and personal hygiene. The resident was independent with eating and was totally dependent on two staff for bathing. The resident had a court appointed guardian (his father) at the time of admission to the facility. The 9/23/15 Amended Order Appointing Guardian for Adult stated, Respondent was involved in a motor vehicle accident resulting in severe traumatic brain injury and spinal cord injury. Respondent suffers severe disorder of cognition, orientation, problem solving, and memory. Due to his current condition, Respondent is not competent to make decisions of personal, medical, legal or financial nature. The following psychotropic medications were identified on the 11/2015 medication administration record (MAR) for administration to the resident: -Risperdal (antipsychotic) 0.5 mg by mouth three times daily for agitation. -Buspirone (anti-anxiety) 5 mg one to two tablets by mouth as needed every six hours for agitation. -Abilify (antipsychotic) 1 mg by mouth on arising for depression. This medication was started at the facility on 11/18/15 and was not part of the original medication regimen from the rehabilitation hospital. -Ambien (hypnotic) 5 mg by mouth nightly at bedtime for insomnia. May repeat dose one time (per night.) -Trazodone (antidepressant with drowsiness as a side effect) 100 mg by mouth nightly at bedtime for insomnia. -Zoloft (antidepressant) 75 mg by mouth daily on arising for depression. II. Failures in Medically Related Social Services A. Family Interview On 2/16/16 at 12:36 p.m. and 2/29/16, an interview with an interested family member, a professional nurse in a hospital setting who regularly visited the resident in the facility and who was involved with the resident's care, revealed she went to see the resident weekly at the facility and called frequently to check on the resident's well being. She revealed the family had requested assistance with locating a facility that was more suitable for the resident at care conferences on 11/19/15 and 12/3/15. The family stated the resident wanted to be around younger people. According to the family member, she heard nothing about discharge planning progress after the 12/3/15 care conference. The family member stated she was concerned the resident was withdrawn and depressed and she had talked with facility staff about getting the resident a psychological consultation/mental health services, but she did not know if that had occurred and did not feel the request was addressed. The family member stated she had brought her concerns about the resident's declining mental status to the nursing staff but did not feel they were addressed. The family member stated she did not communicate with the social service director (SSD) apart from the two care conferences held on 11/19/15 and 12/3/15. The family member stated the resident experienced a decline in his physical and mental well-being while at the facility. The family member said the resident was practically catatonic when he was admitted to the hospital on [DATE]; the resident no longer carried on conversations and had declined in mood to the point of giving one word answers if a response was offered. She said the resident remained in the hospital receiving surgical interventions that included wound debridement, a diverting colostomy in preparation for a muscle flap surgery to repair the pressure ulcer to the sacrum; a feeding tube to enhance nutritional levels to promote wound healing; and the muscle flap procedure with skin graft. The family member stated the resident had finally begun to improve back to his prior mood baseline after being in the hospital for almost two months. Within the past week, the resident was again able to converse with family and was able to ask questions. Per the family member, the resident had received psychiatric care services to help restore his mental state back to the previous baseline. The family member stated she now viewed the resident's care refusals and withdrawal as a kind of cry for help. B. Record Review 1. Failures to Identify and Address Concerns and Adjustment Difficulties a. Timely Mental Health Services Failure A review of the clinical record supported the interested family member's report that the facility delayed obtaining mental health services for the resident. Although the resident had been receiving mental health services at the rehabilitation hospital, the social service department did not provide immediate referral to the facility's mental health services provider in order to provide continuity of mental health services when the resident arrived at the facility. A review of the clinical record revealed the referral paperwork for mental health services was dated 12/29/15, which was approximately six weeks after admission. During the interceding time, between admission and 12/29/15, the resident exhibited withdrawal, self-isolation, and care refusal resulting in skin breakdown. See F319 for record review on individual progress note entries in the resident's clinical record. b. Failures in Assessment and Care Planning Although progress notes showed the resident began to experienced increased withdrawal, care refusals and other behaviors, the clinical record failed to evidence that the patient health questionnaire-9 (PHQ-9) assessment for depression was repeated after 11/20/15, to determine if there was a change in the resident's depression levels. As stated above, the resident was on multiple psychotropic medications. The social service department failed to conduct on-going assessment of the resident's mental health well-being and failed to develop personalized plans of care to help meet the resident's needs. The depression care plan identified the resident's medications for depression and directed staff to observe the resident for signs and symptoms of increasing depression; however, it did not identify how staff was to proceed if increased depression signs were present. The insomnia plan of care identified the resident's medication for insomnia and directed staff to monitor hours of sleep, to administer medications as ordered and to review the medications quarterly. However, there were no resident-specific nonpharmacological interventions identified and no evidence staff implemented the directive to monitor hours of sleep. The medication care plan read to administer medications as ordered, attempt nonpharmacological interventions (identified but no evidence they were resident-specific), document target behaviors, review medications quarterly and use mental health services as needed. However, the resident's target behaviors were not specifically identified in the record and were not being monitored. A review of the clinical record revealed there was no behavior tracking to monitor the episodes of agitation for the use of Risperdal. No description of the target behavior agitation behavior was in the clinical record. Monitoring of hours of sleep related to the use of two medications for sleep was not identified in the clinical record. Tracking to determine if the Abilify, a medication started at the facility, reduced the resident's depression was not present in the clinical record. Finally, there was no direction to staff when use of mental health services would be appropriate. 2. Failures to Pursue Discharge Planning A review of the clinical record supported the interested family members report that the facility did not actively pursue a more appropriate placement for the resident. An 11/19/15 at11:52 a.m., social service note indicated the resident's father (guardian) gave permission for the aunt to attend care conferences and obtain medical information on the resident. Additional notes showed that a care conference was held that day with the next conference being scheduled on 12/3/15. The care conference note in the paper chart stated that resident wanted to be transferred to another facility with younger residents. The admissions director was assisting in locating such a facility. The resident was noted to participate in activities. The clinical record contained no information about discharge planning or locating a more appropriate placement after the 12/3/15 care conference note. 3. Failures to Coordinate Updates Record review confirmed the family member's report that the resident had difficulty adjusting to the facility, began to exhibit increasing signs and symptoms of depression as evidenced by self-neglect neglect (care refusals contributing to self-harm). Record review also confirmed the facility failed to adequately communicate the resident's increasing signs and symptoms of depression to his health care providers and interested family members, failed to identify approaches to assist facility staff in meeting the resident's needs, and failed to timely seek supports for the resident inside and outside the facility. See F319 for record review of individual progress note entries in the resident's clinical record showing an absence of care coordination. C. Staff Interviews (1) Staff member #16, interviewed on 2/17/16 at 7:30 a.m. said s/he believed the resident was not an appropriate admission for the facility. S/he said the resident did not feel he belonged at the facility due to the difference in his age to the generally older population in the facility. (2) Licensed practical nurse (LPN #4) interviewed on 2/17/16 at 10:10 a.m. said the resident made it clear from the time of admission that he did not want to be at the facility. The LPN stated the resident would continually tell staff, I don't belong here. (3) LPN #8, who helped care for the resident, was interviewed on 2/17/16 at 10:10 a.m. The LPN said resident #2 was very depressed, had a flat affect, and was noncompliant with cares. The LPN stated she was unaware of any care plan developed to help staff address the resident's care refusals. The LPN stated the resident made it clear that did not want to be at the facility. The LPN stated it seemed that when he realized he was going to remain at the facility, the resident went into a downward spiral. (4) LPN #6, interviewed on 2/17/16 at 4:41 p.m., stated nursing did not receive much help from the social services director (SSD) related to resident mental health needs. The LPN stated that nursing approached facility leadership (the nursing home administrator and the SSD) about resident #2's diminished mood and care refusals; however, leadership informed them it was none of their business and the resident had the right to refuse. (5) LPN #11, who regularly worked with the resident on the evening shift, was interviewed on 2/18/16 at 1:48 p.m. She said she felt she was not able to meet the resident's needs. The LPN stated she did not know how to care for a resident with TBI-related behaviors. The LPN denied knowledge of any care planning related to helping meet the resident needs related to TBI. The LPN said the facility did not provide education about working with TBI residents prior to or during the time the resident was at the facility. The LPN stated that when the resident was admitted to the facility, he repeatedly informed staff, I don't belong here. The resident also repeatedly asked, When can I leave? The LPN was not aware of any discharge planning for the resident. (6) Registered nurse (RN) #2 was interviewed on 2/18/16 at 5:13 p.m. S/he reported providing cares to the resident and said when the resident arrived at the facility, All he could say was he did not belong here. The RN reported the resident would get up and go outside to smoke, but that changed after being at the facility for a short time. The RN was not aware of social service interventions to help address the resident's decline in mood and behavior. (7) LPN #8, interviewed on 2/19/16 at 11:20 a.m., said the facility had not had new monthly behavior tracking forms available since November (2015).S/he said the facility presently had no formal method for identifying and tracking target behaviors. (8) LPN #9, interviewed on 2/19/16 at 11:25 a.m., revealed the facility had stopped completing behavior tracking for residents. The LPN stated the behavior tracking was supposed to be used to help identify if medications to modify behaviors were effective. A review of the behavior book for the resident's hallway with the LPN revealed documentation that behavior tracking was completed for 11/2015 for individuals on the hall where the resident resided. However, there was no behavior form located for resident #2. (9) The MDS coordinator, interviewed on 2/23/16 at 10:44 a.m., said she had turned over behavior tracking to the SSD when she arrived in 11/2015. The MDS coordinator stated she had heard the SSD was not generating new behaviors forms for nursing staff. The MDS coordinator stated that other than activity staff, she was the only person conducting care planning in the facility. The MDS coordinator acknowledged that the behaviors/medication care plans were not resident-specific. (10) CNA #16, who regularly cared for the resident during his stay, was interviewed on 2/18/16 at 9:23 a.m. The CNA stated the SSD was not helpful in addressing resident mental health and behaviors. The CNA stated said the resident began to withdraw, stay in his room and then refuse cares. Staff was directed by leadership that it was the resident's right to refuse cares. The CNA stated she was unaware of anyone attempting to develop strategies to obtain the resident's compliance with cares. She was never directed to call the resident's guardian or other interested family members to see if they could convince the resident to consent to cares. (11) LPN #11, who was a nurse for the resident during the first few weeks of his stay, was interviewed on 2/18/16 at 1:48 p.m. She revealed she had concerns about the resident's mental health the second week of his admission. The LPN said the only time the resident showed any emotion was when his family would visit. She felt the resident was extremely depressed because he was refusing to eat, and on more than one occasion would only drink or smoke. The LPN stated when a resident refused cares, it was important to educate the person about the consequences of the refusal so they knew what was going to happen. The LPN stated the resident did not have the capacity to understand the consequences of his refusals, which concerned her. The LPN said she was not provided with guidance from the SSD, NHA or anyone else in the facility on how to manage refusals in a mentally incapacitated person. The LPN stated she approached the SSD to express concerns about the resident's placement and declining mental status. The LPN stated that for her efforts, the NHA told her she needed more education in resident rights. (12) Staff member #7, who regularly cared for the resident, was interviewed on 2/18/16 at 5:13 p.m. The staff member said the resident's mood became progressively worse during his stay. The staff member described the resident's stay at the facility as a downhill slide. The staff member stated the resident refused bathing and eventually began refusing all other cares. The staff member stated it was her opinion that the resident required a psychiatric facility to help address mental well-being and to help him cope with his many losses. The staff member stated she was one of the individuals that approached facility leadership, in late 11/2015 or very early 12/2015, about their concerns for the resident and the resident needing a different facility designed to meet his needs. The staff member stated she offered to help locate a more suitable placement, but was told by leadership they were keeping him here. The NHA reportedly stated, This is the best possible place for him. The staff member stated the nursing staff was so concerned for the resident that they approached facility leadership a number of times but always their concerns were dismissed. (13) LPN #7, interviewed on 2/19/16 at 10:02 a.m., revealed she had concerns about the resident's mental health and placement at the facility. The LPN stated she felt the facility was unable to meet the needs of the resident due to his mental state and his care refusals. She said after the resident fell (11/27/15), the resident became difficult to control. The LPN stated she did not believe the resident went out of his room after that incident. The LPN stated she was very worried about the resident's mental status and felt if he could have harmed himself, he would have. The LPN acknowledged the resident's refusal of cares contributed to his worsening of pressure ulcers, sepsis and prolonged hospitalization . The LPN stated the SSD would not communicate directly with floor staff and insisted all communication be through the chain of command, specifically the director of nursing. D. Provider Interviews (1) A mental health practitioner (Masters level prepared) who provided services at the facility was interviewed on 2/18/16 at 10:17 a.m. The practitioner said she had met briefly with the resident while he resided at the facility. She said staff had approached her early in the resident's stay to get the resident seen by her. However, she said that referrals to mental health services were not timely because the SSD did not timely process referral requests from nursing staff. The practitioner said when she attempted to speak the SSD about referrals and resident concerns, the SSD ignored her. The practitioner stated that there were times with the activity director had to intervene to get mental health referral paperwork completed. (2) A psychologist who provided services at the facility was interviewed on 2/18/16 at 10:30 a.m., and 2:48 p.m. The psychologist stated that getting timely referrals and complete referrals from the facility in order to provide mental health services had been difficult. The psychologist stated that he had spoken to the resident in anticipation of a referral for service. The psychologist stated the resident was much younger than the typical resident and was capable of noticing the difference. However, by the time the referral for service was made (12/29/15 per record review), the resident was not willing to associate with anyone at the facility and declined counseling and evaluation services. The psychologist confirmed the resident was referred to counseling on 12/29/15 for symptoms that included memory difficulty, decreased attention, sadness, resistance to care, decreased social interaction, and isolation/withdrawal. Skin breakdown and paralysis were also noted on the referral. This referral was made two weeks after the resident began to experience skin breakdown which the facility leadership (NHA per interview on 2/17/16 at 11:58 a.m.) attributed the resident's right to refuse care. The psychologist stated that the staff at the facility was not able to meet the resident's mental health needs. The psychologist stated that he attempted to bring this concern to the SSD and the NHA but found them unwilling to discuss his concerns for the resident. (3) The resident's physician was interviewed on 2/24/16 at 12:00 p.m. She said the resident was doing well but there was a sudden change and he became more introverted. The physician stated the resident had expressed a desire to not be at the facility. The physician stated she had provided the name of a facility known to have younger residents; however, the facility did not seem to follow-up. The physician reviewed her resident communication notes remotely to determine the communication generated about the resident by the facility. According to the physician, the resident was a long term care patient, so unless the resident had an acute change or the facility reported a need for physician service, the physician saw the patient as allowed under the regulations. Her review of these notes revealed: -Notification of a skin tear during a transfer on 11/25/15. -Notification 12/28/15 the resident was experiencing worsening depression. -Notification 1/3/16, to authorize transport to the hospital for nausea, vomiting and fever. After reviewing her notes, the physician stated that no one at the facility had informed her of the resident's care refusals or informed her of the resident's large, unstageable pressure ulcer to his sacrum or of the wounds to the heels. The physician expressed concerns with communication in the facility. The physician stated that the facility nursing staff was hard to locate, that phone calls were not answered, and follow-up was not completed. The physician stated that nursing staff was stretched so thin, it was difficult to know what was going on with her residents. 4. Social Services Director Interview with the SSD confirmed the facility did not respond timely or adequately to address the resident's mental, psychosocial and physical needs as reported to them and as documented in the resident's record. The SSD was interviewed on 2/19/16 at 10:46 a.m. She said she documented her interactions and work with residents in the electronic record, except for care conference notes, which were documented in the paper record. The SSD acknowledged that after resident #2's 12/3/15 care conference, there was no further evidence that the SSD was following up on alternate placement for the resident. The SSD stated she felt no other facility would want the resident due to his payer status. The SSD stated she did talk to the resident and he had expressed he did not want to be in the facility because he was young. The SSD stated she was aware of the resident's care refusals. The SSD confirmed she did not complete an assessment of depression after the resident began experiencing signs and symptoms of increased depression. The SSD stated she did send a referral to the mental health service to have them evaluate the resident toward the end of his stay. (See above; the referral was sent three working days before the resident's discharge to the hospital.)

Based on family interview, staff interviews and record review, the facility failed to ensure one (#2) of two residents who displayed mental or psychosocial adjustment difficulty received timely, appropriate treatment and services to address documented mental and psychosocial difficulties. Specifically: Resident #2 had mental health needs related to depression, [MEDICAL CONDITION] (TBI) with lower extremity paralysis, impaired cognition, and adjustment to placement in the facility. The facility failed to respond to his needs, voiced on admission and repeatedly after his admission and increasingly expressed by self-neglect (refusals to bathe, to eat or drink, and to comply with skin prevention measures) and by self-isolation. The facility failed to address resident #2's mental and psychosocial difficulties in a comprehensive manner to promote his mental and psychosocial well-being, focusing instead on the resident's 'right to refuse.' The facility failed to adequately communicate the resident's increasing signs and symptoms of depression to his health care providers, his guardian, and interested family members, failed to identify approaches to assist facility staff in meeting the resident's needs, and failed to timely seek supports for the resident inside and outside the facility. The resident was discharged to the hospital on [DATE], with significant declines in his mental, physical and psychosocial well-being. The findings include: Resident #2, age below 55, was admitted to the facility on [DATE] from a rehabilitation hospital. The face sheet showed the resident's [DIAGNOSES REDACTED]. Information provided by the rehabilitation hospital to the facility demonstrated the resident had history of advance stage wound to the sacrum (stage III). Additionally, the resident was known to have no movement of the lower extremities. Per resident #2's record, resident #2 was discharged from the facility on 1/3/16 at 12:00 p.m. and admitted to the hospital for evaluation and treatment of [REDACTED]. The hospital history and physical on 1/3/16 documented a large decubitus ulcer with necrotic skin breakdown of the sacral area, as well as skin breakdown on both heels. The 1/4/16 note read the resident had [MEDICAL CONDITION] with a likely source of multiple decubitus ulcers. It further read the resident was depressed, had a flattened affect and only responded to yes/no questions. A note 1/14/16 read the resident was being seen by psychiatry. A. Resident Status Preadmission- Cognitive/Behavior/Mental Health Information provided by the rehabilitation hospital to facility demonstrated the resident had a history of [REDACTED]. The resident was in a confusion state with severe amnesic symptoms related to the motor vehicle accident that resulted in paralysis and TBI. The resident did not know his exact age or how he came to be in the hospital. The resident had some understanding of his prior life, but did not recall details. The resident had been receiving psychiatric services at the rehabilitation hospital for management of [MEDICAL CONDITION] medications, memory deficits and [MEDICATION NAME], flat affect. Recommendations included in the 10/20/15 psychiatry consultation that suggested [MEDICATION NAME] the [MEDICATION NAME] (antipsychotic) with [MEDICATION NAME] (antipsychotic) to see if it helped with a brighter mood and more interactive capacity. An 11/3/15 psychiatry consultation indicated switching from [MEDICATION NAME] to [MEDICATION NAME] to see if it helps [MEDICATION NAME] him somewhat. At the rehabilitation hospital the resident had been participating in many therapies including occupational, recreational and physical. Notes furnished to the facility from the rehabilitation hospital did not show the resident to exhibit care refusal concerns. B. Resident Status on Admission - Cognitive/Behavior/Mental Health Review of the resident's 11/23/15 admission minimum data set (MDS) comprehensive assessment revealed: -The resident had unclear speech, usually understood others' communications and was usually understood by others. The resident had moderate cognitive impairment as evidenced by a brief interview for mental status score of 12 of 15. -The resident reported feeling down, depressed or hopeless half or more of the days in the past two weeks. The resident reported having trouble concentrating on things such as reading the newspaper or watching television half or more of the days in the past two weeks. -The resident did not exhibit behavioral symptoms impacting the self or others and did not exhibit signs and symptoms [MEDICAL CONDITION] or [MEDICAL CONDITION]. The resident did not exhibit rejection of cares. -The resident required extensive assistance from two or more staff for bed mobility, transfers, dressing, and toilet use. Extensive assistance from one staff was required for locomotion on and off the unit and personal hygiene. The resident was independent with eating and was totally dependent on two staff for bathing. The resident had a court appointed guardian (his father) at the time of admission to the facility. The 9/23/15 Amended Order Appointing Guardian for Adult stated, Respondent was involved in a motor vehicle accident resulting in severe [MEDICAL CONDITION] and spinal cord injury. Respondent suffers severe disorder of cognition, orientation, problem solving, and memory. Due to his current condition, Respondent is not competent to make decisions of personal, medical, legal or financial nature. The 12/21/15 Colorado Medical Orders for Scope of Treatment (MOST) form signed by the guardian showed the resident was to receive cardiopulmonary resuscitation, full treatment, antibiotics, and long-term artificial nutrition. The following [MEDICAL CONDITION] medications were identified on the 11/2015 Medication Administration Record [REDACTED] -[MEDICATION NAME] (antipsychotic) 0.5 mg by mouth three times daily for agitation. -[MEDICATION NAME] (anti-anxiety) 5 mg one to two tablets by mouth as needed every six hours for agitation. -[MEDICATION NAME] (antipsychotic) 1 mg by mouth on arising for depression. This medication was started at the facility on 11/18/15 and was not part of the original medication regimen from the rehabilitation hospital. -Ambien (hypnotic) 5 mg by mouth nightly at bedtime for [MEDICAL CONDITION]. May repeat dose one time (per night.) -[MEDICATION NAME] (antidepressant with drowsiness as a side effect) 100 mg by mouth nightly at bedtime for [MEDICAL CONDITION]. -[MEDICATION NAME] (antidepressant) 75 mg by mouth daily on arising for depression. C. Resident Status after Admission - Adjustment difficulties, Decline in Mood, Care Refusals, hospitalization - Failures in Facility Response 1. Family interview On 2/16/16 at 12:36 p.m. and 2/29/16, an interview with an interested family member, a professional nurse in a hospital setting who regularly visited the resident in the facility and who was involved with the resident's care, revealed she went to see the resident weekly at the facility and called frequently to check on the resident's well being. She revealed the family had requested assistance with locating a facility that was more suitable for the resident at care conferences on 11/19/15 and 12/3/15. The family stated the resident wanted to be around younger people. The family member stated the resident experienced a decline in mood during his time at the facility. The family member stated she was concerned that the resident was withdrawn and depressed and she had talked with facility staff about getting the resident a psychological consultation, but she did not know if that had occurred. The family member stated she had brought her concerns about the resident's declining mental status to the nursing staff but did not feel they were addressed. The family member stated she became aware the resident was refusing cares during a visit to the resident on 12/19/15. She said the resident was odorous and unkempt. When she brought her concern about the resident's condition to staff, they told her the resident refused bathing and other cares. She said staff had not made her aware of the resident's refusals prior to this visit. The family member said the resident was practically catatonic when he was admitted to the hospital on [DATE]; the resident no longer carried on conversations and had declined in mood to the point of giving one word answers if a response was offered. The resident remained in the hospital receiving surgical interventions that included wound debridement, a diverting [MEDICAL CONDITION] in preparation for a muscle flap surgery to repair the pressure ulcer to the sacrum; a feeding tube to enhance nutritional levels to promote wound healing; and the muscle flap procedure with skin graft. The family member stated the resident had finally begun to improve back to his prior mood baseline after being in the hospital for almost two months. Within the past week, the resident was again able to converse with family and was able to ask questions. Per the family member, the resident had received psychiatric care services to help restore his mental state back to the previous baseline. The family member stated she now viewed the resident's care refusals and withdrawal as a kind of cry for help. 2. Record review Record review confirmed the family member's report that the resident had difficulty adjusting to the facility, began to exhibit increasing signs and symptoms of depression as evidenced by self-neglect (care refusals contributing to self-harm). Record review also confirmed the facility failed to adequately communicate the resident's increasing signs and symptoms of depression to his health care providers and interested family members, failed to identify approaches to assist facility staff in meeting the resident's needs, and failed to timely seek supports for the resident inside and outside the facility. Review of the resident's facility record revealed in pertinent part: - 11/16/15 at 1:11 p.m., progress note stated (young age) resident who is upset and states I do not understand why I am at an OLD folks home. Patient has history of TBI and has had a hard time remembering this nurse's name. Patient oriented to unit, a request for a room change was made. Patient refused lunch. Although the notes revealed the resident changed rooms later that day, there was no evidence the guardian, other interested family and physician were notified of the resident's distress regarding this placement. - 11/17/15 11:25 a.m., a social service note stated that a referral was made to the The Learning Center a TBI case management group in Colorado. The resident had requested for different placement. However, there were no additional notes located in the resident's record showing social service was contacted by or obtained information from the Learning Center and no indication the Learning Center was contacted by social service again prior to the resident's discharge. - 11/17/15 at 1:39 p.m., nurse note stated the resident continued to have a flat affect. The resident was described as very withdrawn. The resident was noted to have refused meals and medications. The resident did drink a Coke in the morning but will not eat. The resident continued to repeat, I don't belong here. When can I leave? The nurse explained to resident that the admissions coordinator is working on getting him placed at a more appropriate setting. The resident had poor short term memory recall. There was no indication in the note that social services, guardian (father), other interested family members, or the physician were notified or would be notified the resident was very withdrawn, felt he did not belong, and was refusing both meals and medications. - 11/17/15 at 8:04 p.m., nurse note read the resident continued to have a flat affect. The resident was perceived as very forgetful and needed reminders to eat and drink. The resident was unable to remember why he was at the facility and repeated the same questions over and over. The resident asked, Why am I here, How did I get here, What is your name? and How long he will be here and when can he leave? The note further read that the resident's father and an aunt made decisions for the resident as the resident was unable to make appropriate decisions due to his TBI. - 11/18/15 at 11:31 pm., nurse note read the resident was self-isolating, withdrawn, non-communicative. The resident offered monosyllabic responses to questions. The resident was refusing food and medications. The nurse made four unsuccessful attempts to encourage the resident to take medications by naming the meds, explaining effects and attempting to converse with the resident one-to-one. The resident was drinking small amounts of fluids. The resident required frequent prompting and encouragement to be involved in care like offloading weight in the wheelchair and to position change positions when in bed. The resident asked, When can I go home? Notwithstanding the resident's known cognitive disabilities, his inability to make decisions, and need for guardian, there was no reference in the 11/18/15 note that the resident's increasing signs and symptoms of depression (self-isolating, withdrawn, non-communicative, and food and fluids refusals) were communicated to the resident's guardian (father), other interested family members, and the physician. Moreover, there was no evidence of intervention by social services in seeking internal and external support to address the resident's symptoms. -11/18/15 physician's history and physical stated, It is medically necessary for the patient to participate in physical therapy and occupational therapy, therapy will prevent deconditioning, as well as help the patient regain his abilities to perform activities of daily living. However, an order for [REDACTED]. - 11/19/15 at 11:52 a.m., social service note indicated the resident's father (guardian) gave permission for the aunt to attend care conferences and obtain medical information on the resident. Additional notes showed that a care conference was held that day with the next conference being scheduled on 12/3/15. The care conference note in the paper chart stated that resident wanted to be transferred to another facility with younger residents. The admissions director was assisting in locating such a facility. The resident was noted to participate in activities. - 11/20/15 at 3:49 p.m., social service note stated, Resident is (years old), [DIAGNOSES REDACTED]. Resident's score on BIMS was 12/15 indicating cognition is moderately impaired. Resident's score on PHQ9 (5/27) indicated mild depression. Resident is trying to adjust to facility and staff. Resident will participates in activities of choice. Resident's goal at this time is to stay at facility and possibly be transferred to a facility with resident closer to his age. SSD will assist as needed on a daily basis. However, record review revealed no documentation of alternative placement information and no documentation of social services daily involvement in the resident's cares. The PHQ9 score was not re-evaluated by social services, despite the resident's increasing signs and symptoms of depression noted in his record. - 11/21/15 at 6:32 a.m., nursing note stated the resident slept soundly throughout the shift. Prior to retiring for the evening, resident was quiet and kept to himself. The resident was cooperative but solemn; not angry but reserved. - 11/24/15 at 9:24 a.m., nurse note stated the resident had a flat affect which differed from a note 11/22/15 of the resident's cooperation and engagement. The resident refused to get out of bed this a.m. Staff offered to help get resident up and he declined. Staff brought resident breakfast in bed this a.m. The resident did get up, but only after receiving pain medication. - 11/25/15 and 11/27/15 documented physical concerns, a skin tear from the Foley catheter and a fall from the wheelchair. The first concern was communicated to physician and family, the second concern was not. -The 11/27/15 activity care plan stated the resident had, .little or no activity involvement related to disinterest, depression, poor adjustment to the facility/unit. Resident wishes not to participate. [DIAGNOSES REDACTED]. He is a younger resident and upset he is in an older community. - 11/29/15 at 9:50 a.m., nurse note stated the resident continued to have a flat affect. The resident refuses to reposition himself. The resident will reposition at times while in wheel chair with encouragement. There was no evidence the resident's refusal to be repositioned was communicated to the guardian, other interest family, and the physician. - 11/29/15 at 10:14 a.m., nurse note stated the resident remained in bed. The resident had back pain that was an 8/10 that was treated with pain medication. - 11/30/15 at 11:58 a.m., nurse note read that resident continued to refuse to participate in therapy, activities and going to meals. There was no evidence the resident's refusals were communicated to the guardian, other interest family, and the physician. -12/1/15 at 2:13 a.m., nursing note stated that the resident was being monitored post fall. - 12/3/15 at 5:46 p.m., social service note stated a care conference was held with the resident's aunts. The conference was attended by the Interim Director of Nurses (IDON), admissions director and activity director. The care conference note in the paper chart documented: The resident was refusing all activities. Nursing noted the family was informed of the resident's medication refusals. The family expressed concerns about medication refusals, transferring, bowel management and the resident's skin care. The family wanted the facility staff to have more education on TBI. Social services continued to look for alternate placement. There was concern that the facility was not the best fit for the resident. However, there was no evidence staff took steps to address the refusals they reported at the care conference through internal and external service providers. There was no indication staff considered an interdisciplinary team meeting to address the resident's refusals and the family's concerns and develop interventions to direct staff on how to promote the resident's care. There was no evidence staff received training on how to effectively care for a resident with TBI. Finally, there was no evidence that social services actively pursued an alternative placement for the resident. There was evidence some of the concerns raised in the care conference were communicated to the physician 12/3/15, but the physician notes indicated there was no notification of the resident's refusal of cares, refusal to take medication, and refusal to participate in therapies. -12/7/15 at 5:27 p.m., a nurse note stated the resident was discontinued from physical and occupational therapy due to lack of participation. The resident's father was informed. -12/8/15 to 12/10/15 No progress notes generated; however, plans of care for the resident's depression, [MEDICAL CONDITION], and [MEDICAL CONDITION] medications ([MEDICATION NAME] and [MEDICATION NAME]) were developed 12/10/15. There was no plan of care addressing the resident's difficulties in adjusting to the facility or addressing the resident's refusal in cares, activities, medications, and therapies. Moreover, review of the plans of care for depression, [MEDICAL CONDITION] and [MEDICAL CONDITION] medications revealed they were not resident-specific and gave minimal direction to staff how on how to address these issues. The depression care plan identified the resident's medications for depression and directed staff to observe the resident for signs and symptoms of increasing depression; however, it did not identify how staff was to proceed if increased depression signs were present. The [MEDICAL CONDITION] plan of care identified the resident's medication for [MEDICAL CONDITION] and directed staff to monitor hours of sleep, to administer medications as order and to review the medications quarterly. However, there were no resident-specific nonpharmacological interventions identified and no evidence staff implemented the directive to monitor hours of sleep. The medication care plan read to administer medications as order, attempt nonpharmacological interventions (identified but no evidence they were resident-specific), document target behaviors, review medications quarterly and use mental health services as needed. However, the resident's target behaviors were not specifically identified in the record and were not being monitored. A review of the clinical record revealed there was no behavior tracking to monitor the episodes of agitation for the use of [MEDICATION NAME]. No description the target agitation behavior was defined in the clinical record. Tracking to determine if the [MEDICATION NAME], a medication started at the facility, reduced the resident's depression was not present in the clinical record. Finally, there was no direction to staff when the use of mental health services would be appropriate. - 12/11/15 at 1:13 a.m., nurse note stated the resident remained in his room, in bed. The resident was quiet and withdrawn and non-conversant. The resident speaks only when requesting [MEDICATION NAME] for back pain but appetite good and the resident allowed side positioning. -There were no progress notes from 12/12/15 through 12/14/15. -12/15/15 at 11:43 p.m., nurse note stated the resident at a reddened area to the coccyx. The resident allowed staff to turn him onto his side. -12/16/15 through 12/19/15 no progress notes. - 12/20/15 at 11:38 p.m., note stated the resident was refusing to get up from bed and was refusing to bathe. There was no evidence the resident's guardian, other interested family and physician was notified of care refusals. -12/21/15 - no progress note. - 12/22/15 at 3:27 p.m., social service note stated that the social services director (SSD) faxed all paper on the order for the resident to see mental health provider on 12/21/15 for a consult for depression. However, the documentation from the mental health provider in the chart was all dated 12/29/15. An interview with the psychologist and the master's level prepared mental health practitioner revealed the SSD often did not provide correct/complete information in making referrals, which delayed their execution. - 12/25/15 nurse note documented the resident was out of the facility 4:30 p.m., and returned at 7:30 p.m. The resident refused fluids on return. His sleep medications were held for drowsiness. - 12/26/15 at 3:03 p.m., nurse note read the resident had skin breakdown on his heels. - 12/26/15 11:55 pm., nurse note read the resident's family member called to express concern about the resident's increased depression, sense of hopelessness, resistance to care, declining strength and lack of appetite. The nurse explained to the family member that resident's father had been helpful in working with staff to encourage resident to allow care, but even this effort had recently been ineffective. The resident refused to get out of bed, leave room, eat or be turned and repositioned. The resident sits in darkened room with door and drapes closed, with his eyes closed or turns face to wall. The resident responds in monosyllabic answers. The resident was angry and defiant. When propped to side to off-load weight, the resident would move and/or remove pillows and props in order to lie flat. When staff attempt to reposition the resident, he would loudly refused saying, No, stop it. Get out. The resident would eat bites of meals, taking 250-500cc water and juice per shift. During shift, resident approached five times by staff to have soiled brief changed before allowing to be cleaned and changed. The resident was angrily pushing staff and shouting during care. After being repositioned and propped to side, the resident moved pillow and prop by moving body and physically removing pillows and props. The resident requested staff to get out and close the door. Notwithstanding this note, there was no evidence the staff member writing the note informed the physician of the resident's care refusals. The resident's refusal to remain off-loaded from his back created a situation of self-harm; the stage I pressure ulcer identified on 12/15/15 worsened to become a large unstageable pressure ulcer that required hospitalization and surgery. - 12/27/15 at 1:30 p.m., nurse note stated the resident was very lethargic. The resident took his medications but refused to get up. The resident did not want to talk to staff or roommate. There was no documentation the resident's change in condition was assessed or reported to the physician, guardian and other interested family member. - 12/27/15 at 8:19 p.m., nurse note stated that the resident remained withdrawn and isolated. The resident was non-communicative. The resident refused to get up in his wheelchair or leave room. The resident refused dinner. The resident was resistive to being turned and repositioned. The resident did accept juice, water and nutritional supplement. Again, there was no evidence the physician, guardian, and other interested family were notified of the meal refusal, self-isolation or refusals to be repositioned in the presence of pressure ulcers to the sacrum. - 12/28/15 at 3:43 p.m., nurse note stated that the resident's depression was discussed with the resident's family member. The nurse explained to the family member that over the last two days the resident had seemed even more depressed than usual; the resident was not observed to have his television on and was staring at the wall. The nurse stated the resident typically offered at least a one word answer but not today. The family member agreed with the nurse. The resident declined to get up from bed and declined to have someone come talk to him. The nurse left messages for the resident's father and the physician about the depression concerns. -12/29/15 no progress note. -12/30/15 at 8:50 p.m., nurse note read the resident was noncommunicative and withdrawn. Responses were limited to monosyllabic answers. The resident was lying in darkened room with shades drawn. The resident's television was off and the resident was facing wall. The resident declined dinner. The resident accepted small amounts of water and juice. The resident refused to remain in a position to offload pressured from the pressure ulcer. The resident removed pillows and wedges used for positioning in order to return to lying on his back. There was no evidence in the note that the physician was informed of the self-harm the resident was inflicting by removing positioning devices and lying on his pressure ulcer. The note did not state the physician was made aware the resident was refusing food and limiting fluids. There was no evidence of mental health services. - 12/31/215 at 2:00 p.m., nurse note read the wound doctor educated the resident on the need for repositioning and getting up from bed. Resident replied back to the doctor, I don't want to. I am fine the way that I am. The doctor attempted to educate the resident on the importance of eating and good nutrition to promote healing to his wounds and prevention of new wounds. The resident replied, I will eat what I want & when I want. Resident had poor eye contact during the wound care & while being educated. The resident refused to get up from bed. A large (8cm by 15cm) unstageable pressure wound to the coccyx was noted. Wounds to the bilateral heels were also present. -A 12/31/15 at 9:58 p.m., nurse note read the resident was easily angered and resistive to being repositioned to offload weight from pressure areas. The resident pulled wedges and pillows from back and/or moved until he was lying flat on back. The resident was lying in a dark room, with the lights off and the door closed. The resident refused to get up in his wheelchair. The resident at less than 20% and consumed 500 cc of fluids. There was no evidence the resident's primary physician was not notified of the resident's anger, resistance, and refusals with cares. There was no evidence of mental health services. - 1/1/16 at 11:59 p.m., nurse note read the resident was resistive to care. The resident refused to get up in his wheelchair. The resident moved onto his back after repositioned and kicked off Prevalon boots. The resident's appetite was poor. The resident consumed 800 cc of fluids. The resident complained of nausea which was relieved by consuming ice chips and 7Up. There was no evidence the resident's primary physician was not notified of the resident's anger, resistance, and refusals with cares. There was no evidence of mental health services. -1/2/16 at 10:37 p.m., late entry for the 1/1/16 11-7 shift read the resident had one episode of refusing to be repositioned. -A 1/2/16 at 10:37 p.m., nurse note read the resident was resistive to care. The resident refused to get up in his wheelchair. The resident moved onto his back after repositioned and kicked off Prevalon boots. The resident's appetite was poor. The resident consumed 800 cc of fluids. The resident complained of nausea which was relieved by consuming ice chips and 7Up. - There was no evidence the resident's primary physician was not notified of the resident's nausea, poor appetite, resistance and refusals with cares -1/3/16 at 10:52 a.m., nursing note stated the resident refused repositioning. A telephone order dated 1/3/15 (though it was actually 1/3/16) at 8:35 p.m., stated in pertinent part, to send the resident to a specified hospital via 911 for fever, nausea and vomiting. b. Review of the resident's hospital records revealed in pertinent part: Complete hospital records were unavailable on 2/15/16, when requested, because the resident remained a patient at the hospital. Hospital policy disallows release of records for in-patients as the records are considered incomplete; however some records were able to be released and are summarized below. A 1/4/16 physical exam note from the hospital stated the resident was, depressed, flattened affect; only responds to yes/no questions. A 1/14/16 psychology note stated the resident was Seen by psychiatry due to refusal of care routines and vegetative depression. The note indicated the resident did not appreciate the significance of his mental status. The resident required repetitive education on his current status, course of treatment, and the need to be cooperative with cares. A 1/18/16 psychology note stated the provider was educating the resident's care staff on consistency of approach and style for each interaction with the resident. The resident was responding to open ended questions with couldn't remember. 3. Interviews with facility staff and health care providers a. Facility staff Staff interviews corroborated family interviews and record review regarding the resident's adjustment difficulties and the social services' failure to timely intervene and follow-up on more suitable placement for the resident. Staff interviews also confirmed the resident exhibited increasing signs and symptoms of depression, as evidenced by self-neglect (care refusals contributing to self-harm) and self-isolation. Staff expressed they did not know how to work with the resident, were not trained in how to address his refusals, and indicated facility interventions were limited to medication management which they confirmed was not being monitored. Staff stated they reported the resident's increasing depression to facility leadership, but leadership indicated it was an issue of resident rights and confirmed no action was taken to provide the resident mental health se

Based on observation, record review and staff interviews, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one (#4) of three of 24 sample residents. Specifically, one staff member was unable to support the resident who was standing at the sink when an assisting staff member left the room. The resident fell , fracturing her right femur. Findings include: Record review Resident #4 was admitted to the facility on [DATE] and readmitted [DATE]. [DIAGNOSES REDACTED]. without current pathological fracture; essential hypertension and chronic obstructive pulmonary disease. The Minimum Data Set (MDS) assessment dated [DATE] identified the resident as having adequate hearing, clear speech, sometimes was able to be understood and sometimes understood others. Vision was adequate without corrective lenses. No Brief Interview for Mental Status (BIMS) was done because the resident was rarely/never understood. The only behavior exhibited by the resident was verbal behaviors directed at others which occurred one to threedays during the look back period. Functionally, the resident required the extensive physical assistance of two persons for bed mobility, transferring, dressing, toilet use and personal hygiene. The resident was always incontinent of bladder and bowel. On 12/2/16 at 3:55 p.m. the resident's fall care plan was reviewed. The care plan focus was last revised 3/31/15. The goal was last revised 4/9/14. All of the fall interventions were from 2012, 2013 and 2014. There was no revision of the fall care plan following the fall on 10/17/15 (see below). The care plan indicated the resident was at risk for falls and required two person assist with transfers as needed. Since 1/9/12, the resident had been identified for the 'falling star program' made to alert staff that she was a high fall risk. The facility submitted a falls and fall risk policy from MED-Pass 2001 (revised September 2012). Paragraph 4 under Monitoring and Follow-Up reads: If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling (besides those that have already been identified) and will re-evaluate the continued relevance of current interventions. A nursing progress note dated 10/18/15 at 5:57 a.m. documented, in pertinent part, 10/17/15 11:35 p.m. 3-11 (3:00 p.m. through 11:00 p.m.) RN (registered nurse) supervisor.: Resident had a fall incident at around 21:15 (9:15 p.m.). Per assessment by the RN supervisor resident noted with facial grimacing and guarding right hip area with limited mobility to RLE (Right lower extremity) or right hip area. Resident able to state that she is in pain but unable to describe the type and the level of pain. The note documented the Nurse Practitioner and resident's daughter were notified. The Nurse Practitioner ordered a STAT (as soon as possible) right hip X-ray. A nursing progress note dated 10/18/15 12:35 a.m. documented an X-ray technician present in the resident's room preparing the resident to be X-rayed. A nursing note dated on 10/18/15 at 4:10 a.m. documented the X-ray result was received by fax. The resident had sustained a right hip fracture. The resident's Nurse Practitioner was advised of the result and gave a new order to transfer the resident to a local Hospital emergency room for further evaluation. A Physician Assistant Progress note dated 10/21/15 noted in pertinent part: Resident readmitted to facility post hospitalization for fracture right femur. Hip fracture occurred on Saturday10/17/15 as resident was assisted in transfer with one assist. Resident was too heavy and assist unable to support. Lowered to floor but lost control and resident landed abruptly. An incident report form dated 10/18/15 at 1:15 a.m. described the incident in pertinent part: CNA states pt (patient) was standing at sink while CNAs (certified nurse aides) were to change and clean resident. One CNA was holding resident under her right upper extremity as pt started moving back. CNA held onto pt as she fell to sitting position near the foot of the bed, scraping her right mid back. The incident report did not indicate level of pain. The report noted the resident could ambulate short distances with the assistance of two staff. The resident was documented to be alert and oriented to herself only. The report documented no injuries observed post incident. No predisposing environmental factors were indicated. Impaired safety awareness and gait imbalance were listed as predisposing physiological factors. Observation On 11/25/15 at 2:22 p.m. the resident's room was observed. Neither resident was in the room at the time. The resident's bed was made up, in the low position, and the call light was lying on the bed. The fall mat was folded and stored in front of a chest of drawers. The room was uncluttered. On 12/1/15 at 10:47 a.m. the resident's room was observed. Again, neither resident was in the room. The room was uncluttered, and the fall mat was folded up at foot of bed. The call light lying on bed. On 12/2/15 at 4:20 p.m. a third observation of the resident's room was done. All observations were consistent with prior observations. Staff Interviews The two CNAs noted in the incident report were no longer available at the facility for interview during survey. One CNA was from an outside agency and the other was no longer employed; both were not available. RN #3 was interviewed on 12/2/15 at 3:49 p.m. RN #3 reviewed nursing notes for resident #4 and stated that it appeared from documentation that it was not noted who was with the resident when the resident fell . She thought the resident had one agency CNA with her at the time of the fall. RN #3 was unable to find the note documenting the fall on 10/17/15 at 9:15 p.m. (the note was entered 10/18/15 at 5:57 a.m., eight hours following the fall and was not documented as a late entry. RN #3 was familiar with resident #4. When asked how the resident should be cleaned and changed she said: Typically, she lies on her back in bed. She rolls from side to side to assist in removing the soiled undergarment. After perineal care is done, the resident is rolled side to side again to place a new undergarment. Dirty linen/incontinence products are removed and the resident is repositioned in bed. CNA #1, who worked with resident #4 frequently, was interviewed on 12/2/15 at 4:22 p.m. CNA #1 said that she had the assistance of another CNA when transferring resident #4. She (resident 4) is not steady on her feet anymore. The Director of Nursing (DON) was interviewed 12/2/15 at 5:31 p.m. When asked if a resident with Alzheimer's dementia, generalized muscle weakness and age-related osteoporosis should be changed and cleaned standing at the sink, the DON replied this care should have been done with the resident (#4) lying in bed.

Based on observations, record reviews, and interviews, the facility failed to provide two (#38 and #14) of the sampled 67 residents medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of the residents. Specifically, the facility failed to provide routine and emergent dental services. Findings include: I. Expectations for Pain Management A. Professional Reference: "Clearly, for many years clinicians have been placed in a challenging situation...they had no standards for assessment and treatment (of pain)...Critical to correcting this is establishing a standard for assessing the existence and intensity...if caregivers do not agree on a standard for assessing pain intensity, each is likely to assess pain differently...the care of a single patient can vary from one caregiver to another, very likely resulting in unrelieved pain... Many studies have shown that either lack of pain assessment or the existence of differences between the clinicians' pain ratings and those of patients is a major cause of inadequate pain management. Source: McCaffery, Margo and Pasero, Chris, "Pain: Clinical Manual," 2nd edition, Mosby, St. Louis, 1999, pp. 5 and 36. P. 732 in McCaffery M, Pasero C: Pain: Clinical Manual, Copyright 1999, Mosby, Inc. Standards for Pain, Assessment, Treatment, and Documentation, in pertinent part, states: " -Patients will be promised attentive analgesic care by being informed verbally and in writing at the time of their initial interview that effective pain relief is an important part of their treatment, that their report of unrelieved pain is essential, and that staff will respond quickly to their reports. -Patients will be taught to use a pain rating scale. When patients are taught to use the pain rating scale, they will be asked to set a comfort (pain relief) goal. Patients will be told that pain rated above the goal ...will trigger an analgesic dose increase, additional analgesic, other pain relief intervention. -Pain ratings that are persistently above the comfort goal will trigger interdisciplinary review of the pain management plan and a modification in treatment. " II. Facility Policies: a. Social Services As it pertains, the revised 12/10 social services policy and procedure included: -The Director of Social Services is a qualified social worker responsible for: consultation with other departments regarding program planning and priority setting of social services; consultation to allied professional health personnel regarding provisions for the social and emotional needs of the resident and family; an adequate record system for obtaining, recording, and filing of social service data. -The social services department is responsible for: compiling and maintaining up to date information about community health and service agencies available for resident referrals; maintaining appropriate documentation of referrals and providing social service data summaries to such agencies; working with individuals and groups in developing supportive services for residents according to their individual needs and interests. b. Dental Services As it pertains, the revised 12/09 dental services policy and procedure included: -Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. -Social Services personnel will be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary. -A complete record of the resident's dental care and services are maintained in accordance with current regulation. -All dental services provided are recorded in the resident's medical record. c. Availability of Dental Services As it pertains, the revised 8/07 availability of dental services policy included: -Social Services will be responsible for making necessary dental appointments. -All requests for routine and emergency dental services should be directed to Social Services to assure that appointments can be made in a timely manner. -Inquiries concerning the availability of dental services should be referred to Social Services or to the Director of Nursing. III. Resident #38 Sample resident #38, age 70, was initially admitted to the facility on [DATE] and readmitted again on 11/6/13. According to the admission record, the resident was diagnosed with [REDACTED]. The 5/27/14 Minimum Data Set (MDS) was reviewed. The brief interview for mental status (BIMS) showed a score of three out of 15 indicating severe cognitive impairment. Section G revealed the resident required extensive assistance with personal hygiene including the need for brushing teeth. Section L did not identify any oral or dental problems. On a subsequent MDS quarterly assessment dated , 3/2/13, section L was left blank with no reported oral or dental problems. Observations: On 8/26/14 at 4:41 p.m., the resident was observed in the activity room seated in her manual wheelchair. She appeared slightly disheveled and when she spoke, a strong mouth odor was present. When the resident smiled, both her upper and lower gums were inflamed. The gum lines were colored a deep red. Her teeth were stained with a blackish tint and there was a heavy amount of plaque build-up on her teeth and throughout her surrounding gum beds. The resident was unable to respond to questions associated with dental services. She was not alert or oriented to self. On 8/28/14 at 12:00 p.m., the resident was seated in the milieu in front of the television. When the resident spoke, a strong mouth odor was present. Her teeth remained heavily stained and when she smiled, her gums appeared less inflamed and tinted a purple hue. Her gums appeared to be receding from her natural teeth. On 8/29/14 at 8:38 a.m., two certified nurse aides (CNA #4 and CNA #8) provided cares to the resident inside her room. CNA #4 located the resident's toothbrush inside her dresser drawer and reported to CNA #8 the resident did not have any toothpaste. CNA #8 obtained more toothpaste and the paste was applied to the resident's toothbrush. The toothbrush was handed to the resident who was able to brush her teeth with force. She brushed around the edges of her teeth and when she spit the foam out of her mouth, blood was observed on the toothbrush and blended into the foam the resident had spit out into the sink. CNA #8 was asked to stop her other tasks and observe. CNA #8 confirmed blood was coming from the resident's gums and when she asked the resident if she was having pain, the resident responded her mouth hurt and she was uncomfortable. The toothbrush fell on the resident's floor and CNA #4 threw away the toothbrush without replacing it after cares were completed. On 8/29/14 at 11:20 a.m., the licensed practical nurse (LPN #4) observed the resident's teeth. The resident was seated in the milieu. LPN #4 verified the resident's gums were inflamed and retracting away from her natural teeth. LPN #4 reported the resident's teeth did not look healthy and were discolored. Record review: A review of the resident's medical record revealed [REDACTED]. dentist to act as the resident's dentist while a resident. There were no dental consults available in the resident's record to indicate the facility had provided any routine or emergent services to the resident. There was no documentation of any refusal of dental services. The resident's comprehensive care plan was reviewed. There was no specific oral care plan in the resident's record and there was no mention of oral care needs in any of the developed care plans associated with the resident. The progress notes available in the resident's record between 3/1/14 and 8/29/14 were reviewed. There were no notes from social services to show the resident or resident's representative were asked, discussed, or offered dental services. There was one care conference note to refer to in the resident's chart during the period mentioned above and again, no documentation was available to show the facility discussed the need for oral care services. The facility was asked to provide six months worth of sign ups sheets for dental services. A review revealed the facility had only signed resident up for dental services on 6/26/14 which resulted in no routine services rendered due to no dentist available to perform routine dental services. The 9/14 sign up sheet also provided. The social worker did not have the resident #38 on the list for dental services although resident breath was malodorous, gums bleeding, and teeth stained and observed with plaque build-up. The resident was not added until addressed with the facility during survey. Interviews: On 8/29/14 at 9:01 a.m., CNA #8 was interviewed. She stated the resident's teeth were a yellowish color. She stated the resident usually had a common mouth odor and it wasn't usually reported to the nurse. She said it was common for the resident to have a strong mouth odor. On 8/29/14 at 9:17 a.m., CNA #4 was interviewed. CNA #4 reported the resident had habitually bad breath which could be a result of periodontal disease. She stated bleeding observed during cares should be reported to the nurse. CNA #4 was unable to provide information regarding the facility dentist and stated she could only assume the facility had a consulting dentist. On 8/29/14 at 11:18 a.m., LPN #4 was interviewed. She stated she was informed by the CNAs of the resident's gums bleeding during cares and was informed her gums had stopped bleeding. She did not state she was informed the resident had reported her mouth had hurt or that the resident had reported she was uncomfortable. LPN #4 reported, from her past observations, that the resident was receptive to opening her mouth when prompted; and the resident's teeth were discolored. She stated a more sensitive toothpaste for the resident should be considered and discussed with the resident's nurse practitioner for notification and suggestions. LPN #4 was unable to provide information regarding the facility dentist and stated she could only assume the facility had a dentist. On 8/29/14 at 11:37 a.m., the social services director (SSD) was interviewed. The SSD reported there were problems she inherited with the post-eligibility treatment of [REDACTED]. The SSD said she just recently coordinated services with a dentist willing to provide services to residents needing routine and emergent dental services. The SSD stated the facility had been reacting to dental issues in the facility instead of being in a position to be proactive. She stated the facility was not providing preventative dental services to the residents residing in the building. She stated when oral pain was reported, residents would not go more than one or two days without services, however, the resident had reported her mouth cavity hurt and she was uncomfortable. Instead of the SSD placing a call for emergent dental services, the resident was added to the sign up list for dental services, date to be determined. On 8/29/14 at 12:18 p.m., the nursing home administrator (NHA) was interviewed. The NHA stated there were problems with the financial process for ancillary services to be rendered to residents of the facility. The NHA reported the dental provider has not received their money for past services provided to the residents. The NHA reported the facility was responsible for ensuring residents received routine dental services and he was not aware the residents had been without dental services. Follow-up: On 9/4/14 at 10:15 a.m., the dental provider was contacted. The hygienist coordinator reported a dentist would be out to the facility on [DATE] to provide dental services. The executive director (ED) reported the facility was behind a significant amount of money for services provided in the past which postponed future services. The ED acknowledged they would be continuing services to the facility residents and believed some resolution will be seen with the new payment system through Medicaid. The information provided by the dental provider indicates the facility failed to locate additional dental services as they worked to resolve the monetary billing issues with their primary dental provider. IV. Resident #14, [AGE] years of age, was admitted to the facility, on 8/14/13 and re-admitted on [DATE]. Her diagnoses, according to face sheet, included dementia, epilepsy, lupus and cognitive deficit. According to the significant change Minimum Data Set assessment (MDS), dated [DATE], the brief interview for mental status (BIMS) showed a score of 8 out of 15 indicating moderately impaired. Her speech was clear and she was able to make herself understood, and she understood others. Section L (oral/dental) status was coded as the resident having no issues and section J (pain management) revealed that the resident was receiving scheduled and PRN (as needed) pain medications. The pain intensity was noted 7 in scale 0-10. Resident interviews The resident was interviewed on 8/27/14 at 7:45 a.m. When the resident was asked if they had any pain or discomfort she replied "no." When she was asked do you have mouth/facial pain with no relief she said: "Yes, I had a toothache for quite some time and I haven't seen a dentist for over six months. I told the nurses, social services (SSD name) and still haven't seen the dentist." After the conversation with the resident the SSD was informed right away of the above findings and complaint of tooth pain. On 8/29/14 at 9:30 a.m., the residents care was observed and the surveyor over-heard the resident complaining to the certified nurse aide (CNA #11) about toothache. On 8/29/14 at approximately 11:00 a.m., the surveyor and the SSD went to the resident's room and the resident verified that her tooth hurt and she had notified the SS (name) and requested a dental appointment several times in past several weeks. Record review The medical record was reviewed from 1/28/14 till 9/2/14 (exit day). There was no evidence of any visits from the dentist; there were no notes in the SS section regarding resident complaints of the tooth pain even after the SSD was notified by the surveyor on 8/27/14 at approximately 8:30 a.m. Moreover there was no evidence of the care conferences for past seven (7) months and there was no care plan regarding oral status. Electronic Medication Administration Record (e-MARs) for August 2014 revealed the resident complained of pain 17 times in the day shift and one time in the evening. The resident was medicated with PRN (as needed) Tylenol 500 mg and Ultram 50 mg (pain medications) on top of the scheduled Tylenol 650 mg three times a day. [DATE] e- MARs revealed the resident complained of pain twice in the day shift and once in the evening. Resident Council Meetings for 6 months were reviewed. On May 13 2014 was announced by the social services "Dentist- to be scheduled with new dentist. Anybody having emergency toothache will get in right away." Staff interview On 8/29/14 at 11:30 a.m., the licensed practical nurse (LPN #1) who was familiar with resident #14, verified that the resident was complaining of the toothache for the past several weeks and the SSD was informed by her as well as by the resident. On 8/29/14 at 11:40 a.m., CNA #4 also verified that the resident had lately complained of the tooth pain and her gums were bleeding. She reported to the nurse and she overheard the resident talk with the SSD about that. Facility failure: The SSD was aware of the resident's complaints of the tooth pain for several weeks. The SSD did not schedule the dentist visit after the first notification by the surveyor on 8/27/14 till the exit 9/2/14, for seven days. The social services note dated 8/29/14 at 2:46 p.m., read in pertinent part: "Resident is reporting having teeth pain. Resident is on dental list for September visit."

Based on observations, record review and interviews, the facility failed to ensure four (#36, #25, #39, and #45) of 31 sample residents who entered the facility without pressure sores did not develop pressure sores and residents having pressure sores received the necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Specifically: The facility failed to adequately track and monitor pressure ulcers to ensure management of ulcers was effective in promoting healing and in preventing complications. Observations revealed undiscovered areas of skin breakdown (residents #25 and #39) and areas of tunneling (resident #45) that were not being treated. The findings include: A. Professional Reference The Clinical Practice Guideline, Number 15; treatment of [REDACTED].S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research. AHCPR Publication No. ,[DATE] on [DATE], reads in pertinent part: "Assessment: Assess the pressure ulcer (s) initially for location, stage (NPUAP, 1989), size, sinus tracts, undermining, tunneling, exudates, necrotic tissue, and the presence or absence of granulation tissue and [MEDICATION NAME] ...Pressure ulcers should be uniformly described to facilitate communication among staff and to ensure adequate monitoring of the progress toward healing ...Necrotic tissue must be removed before the stage of the ulcer can be determined. To monitor progress or deterioration of the lesion, the examiner must accurately measure the length, width, and depth of the ulcer and describe sinus tracts, tunneling, undermining, necrotic tissue, exudates, and the presence or absence of granulation tissue and [MEDICATION NAME] (Yarkony, Kirk, Carlson, et al., 1990) ... Indicators of a deteriorating pressure ulcer include increases in exudate and wound [MEDICAL CONDITION], loss of granulation tissue, and a purulent discharge ..." On [DATE] at 3:31 p.m. the following information was downloaded from this site: <http://www.ahrq.gov/professionals/systems/long-term-care/resources/pressure-ulcers/pressureulcertoolkit/putool3.html>. "... three critical components in preventing pressure ulcers: Comprehensive skin assessment. Standardized pressure ulcer risk assessment. Care planning and implementation to address areas of risk ...Comprehensive skin assessment is a process by which the entire skin of every individual is examined for any abnormalities. It requires looking and touching the skin from head to toe, with a particular emphasis over bony prominences. As the first step in pressure ulcer prevention, comprehensive skin assessment has a number of important goals and functions. These include: -Identify any pressure ulcers that may be present. -Assist in risk stratification; any patient with an existing pressure ulcer is at risk for additional ulcers. -Determine whether there are other [MEDICAL CONDITION] and skin-related factors predisposing to pressure ulcer development, such as excessively dry skin or moisture-associated skin damage (MASD). -Identify other important skin conditions. -Provide the data necessary for calculating pressure ulcer incidence and prevalence..." B. Facility Policy - Pressure Ulcer Management (in pertinent part) On [DATE] at 2:30 p.m., a copy of the facility's Pressure Ulcer Management Policy and Procedure not dated was reviewed. The following documented the facility's system for monitoring and managing pressure ulcers (PU) (in pertinent part): "1. The Charge Nurse will be responsible to assess the Pressure Ulcer to include: Site/location of the pressure ulcer, staging of the pressure ulcer, size in cm (length X (by) width), appearance of the wound bed, depth, undermining, drainage/exudates to include the type/amount, color of the wound bed, and surrounding skin color and any pain related to the pressure ulcer. The Charge Nurse or designee will be responsible to initiate a Weekly Pressure Ulcer Healing Assessment tool-Briggs form 3169HH ... 3. The Charge Nurse or designee will be responsible to complete an initial narrative note in the resident's medical record to describe the resident's identified risk factors and a description of how the pressure ulcer most probably occurred if known ... 10. Any resident who has a Stage III or IV pressure ulcer-nursing will be responsible to complete daily documentation on the progress of the wound. 11. Weekly the Wound Nurse or designee will conduct wound rounds and record results on the Weekly Pressure Ulcer Tracking Log. This report will be submitted to Nurse Consultant via email or fax weekly. 12. The facility will have an Interdisciplinary Team meeting to review current treatment plans and initiate any revisions/changes to the plan of care as indicated." C. Resident Failures The facility failed to accurately assess and document facility-acquired pressure sores. 1. Resident #25 Resident #25, a [AGE] year old male, was admitted to the facility on [DATE] with diagnoses, per the face sheet, that included [MEDICAL CONDITION] due to [MEDICAL CONDITION], dementia with behavioral disturbances, [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], [MEDICAL CONDITIONS], history of falls, convulsions, and diabetic type II. On [DATE] the Quarterly Minimum Data Set (MDS) documented the resident had long- and short-term memory impairments. His cognitive skills for daily decision-making were severely impaired. -He was totally dependent on staff for personal hygiene, eating, and bathing. He required extensive assistance of two persons with bed mobility, transfers, dressing, and toileting. -He had one stage II pressure ulcer that he had acquired at the facility on [DATE]. He had skin tears during this assessment period. He had a pressure reducing device for wheelchair (w/c) and bed. He had received pressure ulcer care and dressings to his feet. a. Resident Status Copies of the resident's care plans were obtained from the Director of Nursing (DON) on [DATE] at 2:30 p.m. Care plans revealed the resident had multiple risks for skin breakdown (and actual skin breakdown on [DATE]), including disease process (stroke), functional immobility, cognitive impairment, incontinence and nutritional decline. Care plan review revealed: (1) The resident "requires assist with toileting 2nd (secondary) [MEDICAL CONDITION], Dementia with Behavior Disturbance, Legally Blind, [MEDICAL CONDITION](hypertension). Date Initiated: [DATE] Revision on: [DATE]." The interventions included the following: "...Define interventions to prevent skin breakdown from prolonged expose to urine and stool with checking and or toileting at least every ,[DATE] (two to three) hours as needed, applying protective barrier after each incontinent episode and encouraging fluid intake. Date Initiated: [DATE] ...Peri care after each incontinent episode. Date Initiated: [DATE] ..." (2) The resident "is at risk for skin breakdown due to incontinence and impaired mobility due to [MEDICAL CONDITION], Dementia with Behavior Disturbance, Skin fragile. -[DATE] abrasion to R (right) great toe. -[DATE] Skin tear noted to left lower leg. -[DATE] Stage II, 1 (one) cm (centimeter) x 1 (one) cm to Right Heel. [MEDICATION NAME] in place. - [DATE] Right elbow noted with skin tear and bruise. Etiology unknown. -[DATE] Skin tear to right lower arm with bruise and abrasion to left lower extremity, later aspect of calf. Date Initiated: [DATE] Revision on: [DATE]." The interventions included the following: "-Apply moisture barrier after each incontinent episode. Date Initiated: [DATE] -Assist with ADL's (activities of daily living) as needed. Date Initiated: [DATE] -Call light in reach, answer promptly. Date Initiated: [DATE] -Daily skin checks. Date Initiated: [DATE] -Encourage food and fluid completion. Date Initiated: [DATE] -Encourage frequent position changes. Date Initiated: [DATE] -Keep pressure off right heel; monitor q shift for s/sx of infection till healed. Date Initiated: [DATE] -Keep skin clean and dry. Date Initiated: [DATE] -Monitor affected area for redness, swelling, and drainage. Notify M.D. Date Initiated: [DATE] Revision on: [DATE] -Monitor affected areas of skin for worsening of condition or for s/x of infection/c/o pain and report. Date Initiated: [DATE] -Monitor labs as ordered by M.D. Date Initiated: [DATE] -Notify M.D. and family of any skin breakdown. Date Initiated: [DATE] -[MEDICATION NAME] to right heel, change q (every) 3 (three) days. Date Initiated: [DATE] -Pressure reducing mattress in bed. Date Initiated: [DATE] -Pressure relieving cushion while in w/c. Date Initiated: [DATE] -Right heel protector boot while in bed to float heels. Date Initiated: [DATE] -Use arm pads on w/c to prevent skin tears. Date Initiated: [DATE] -Wears briefs/pads. Date Initiated: [DATE] -Weekly skin assessments. Date Initiated: [DATE]." (3) The resident "has potential alteration in intake r/t (related to) variable p.o. (by mouth) intake at meals, dependence on staff for food and fluid intake, and requires texture modification to facilitate chewing/swallowing. Resident has increased nutrition needs for wound healing support. Actual weight loss noted." Date Initiated: [DATE] Revision on: [DATE] The interventions included the following: "-Diet as ordered. Monitor p.o. intake. Date Initiated: [DATE] Revision on: [DATE] -Monitor labs when available and skin (healing of wounds). Date Initiated: [DATE] ... - ...Supplement as ordered. Date Initiated: [DATE] Revision on: [DATE] ..." The resident "has an ADL (activity of daily living) Self Care Performance Deficit r/t (related to)[MEDICAL CONDITION],[MEDICAL CONDITION](hypertension) and Dementia with Behavior disturbance. Date Initiated: [DATE]." The interventions included the following: "-The resident requires a total of 2 (two) staff members for participation with transfers and toileting. Date Initiated: [DATE] Revision on: [DATE] -The resident requires total assist with eating and meal completion. Date Initiated: [DATE] Revision on: [DATE] -Locomotion: resident requires total assist with w/c (wheelchair) mobility. Date Initiated: [DATE] ... -Remove shoes when in recliner. Date Initiated: [DATE] -Bed Mobility: The resident requires total of 2 staff participation to reposition and turn in bed. Date Initiated: [DATE] Revision on: [DATE] ..." Review of the Computerized Physician order [REDACTED]. -The resident's CPO dated ,[DATE] indicated wound care orders initiated on [DATE]. The wound care orders read in pertinent part, "cleanse open area at right (R) heel, pat dry, apply opt-foam (a cushion dressing without medication as indicated by Director of Nursing/DON on [DATE] at 6:45 p.m.) every 3 days ...pressure ulcer." -Further review of the CPO dated ,[DATE] read in pertinent part: "daily skin checks ...Keep pressure off (R) heel and monitor QS (every shift) till healed for s/sx (signs and symptoms) of infection on 1x1 cm open area - QS every day ...Right heel protective boot while in bed to float heel - QS Everyday ...Skin..Assessment q (every) week on Tuesday." However, these orders were not noted on the ,[DATE] MARs or TARs. On [DATE] the Braden Scale for Predicting Pressure Sore Risk documented that the resident was at high risk for pressure sores. b. Failures after discovery of open areas - failure to assess the open areas and document assessments in a manner to monitor their on-going status QI Log: On [DATE] at 2:30 p.m., a copy of the Weekly Pressure Sore Quality Indicator (QI) Log was obtained from the DON. The Weekly Pressure Sore QI Log - a look behind quality assessment tool first initiated by the facility [DATE]- documented the wound measurements by length by width by depth. This record was not kept in the resident's medical chart. Review of the QI log revealed wound description was not documented on this form except for odor and drainage, which was documented as a yes or no. The QI log for resident #25 read: -[DATE]: right heel stage II: 0.5 centimeter (cm) by 0.7 cm. No documentation of wound depth. No documentation of odor or drainage or appearance (color of the wound bed and surrounding skin color) or documentation of pain related to the pressure ulcer). -[DATE]: right heel stage II: 4 cm by 2 cm. No documentation of wound depth. No documentation of odor or drainage or appearance (color of the wound bed and surrounding skin color) or documentation of pain related to the pressure ulcer). -[DATE] the wound was identified as facility-acquired on [DATE]: right heel stage 2: 1.5 cm by 1.3 cm by 0 cm. No was mark for odor and no for drainage. There was no documentation of wound depth or appearance (color of the wound bed and surrounding skin color) or documentation of pain related to the pressure ulcer). -[DATE]: right heel stage II: 1.5 cm by 1.2 cm. No documentation for depth except it read 'scabbed.' No was marked for odor and no for drainage. There was no documentation of the surrounding skin or of pain related to the ulcer. -[DATE]: right heel stage II: 0.7 cm by 0.8 cm. No documentation of wound depth, no documentation if the wound was still scabbed. No was marked for odor and no for drainage. -[DATE]: right heel stage II: 0.7 cm by 0.8 cm by 0.1 cm. Yes was marked for odor and yes for drainage. There was no documentation on the color of the wound bed and surrounding skin or documentation of pain related to the pressure ulcer. -[DATE]: right heel stage II: 0.7 cm by 0.8 cm. Nothing documented for depth. No was marked for odor and no for drainage. No further wound measurements were provided after [DATE]. There was no documentation found in the resident's chart or from the electronic record regarding the wound bed description, exudate amount/consistency, odor description, tunneling/undermining descriptions, necrotic tissue, and/or granulation/[MEDICATION NAME]. Skin Assessments (in pertinent part): On [DATE] the Skin/Oral Assessment documented, "Resident alert & oriented x1 (one). Unable to voice needs staff to anticipate needs. Skin warm, and dry. Small scabbed area RT shin, scratches LT shin, no s/s of infection noted..." On [DATE] the Skin/Oral Assessment documented, "Skin warm, and dry ...Scabbed areas LT small toe, and RT small toe, and bilateral shin, no s/s of infection noted. Open area RT heel, [MEDICATION NAME] in place..." The assessment included no reference to the resident's right heel ulcer identified [DATE].' On [DATE] the Skin/Oral Assessment documented, "Skin warm, and dry. Scabbed areas bilat shin, LT and RT small toes ...RT heel, [MEDICATION NAME] continued..." The assessment included no description of the resident's right heel ulcer. On [DATE] the Skin/Oral Assessment documented, "...RT heel [MEDICATION NAME] in place..." The assessment included no description of the resident's right heel ulcer. On [DATE] the Skin/Oral Assessment documented, "Skin w/d/i with healed skin tear with resolving bruise to right elbow and forearm. Trace bilat pedal [MEDICAL CONDITION] ...skin turgor fair." The assessment included no description of the resident's right heel ulcer. On [DATE] the Skin/Oral Assessment documented, "Skin warm, and dry. Scabbed areas bilateral shin, and RUE (right upper extremity), no s/s (signs/symptoms) of infection noted. RT (right) heel scabbed, [MEDICATION NAME] dressing in place..." The assessment included no description of the resident's right heel ulcer. On [DATE] the Skin/Oral Assessment documented, "Skin warm, and dry ...no s/s of infection noted. Discoloration bilateral shin remains evident..." The assessment included no reference to the resident's right heel ulcer. On [DATE] the Skin/Oral Assessment documented, "Skin w/d/I (warm/dry/intact). Skin intact with no open red areas noted. Few scattered old scabs to bilat (bilateral) shins. Skin turgor fair... " The assessment included no reference to the resident's right heel ulcer. c. Wound Observations On [DATE] at 2 p.m., the resident's right heel was observed with the resident's permission by two Registered Nurses (RN). A specialized pressure reduction mattress was in place for the resident although the resident was lying on top of his bed with multiple layers of coverings placed under him. The resident's (R) lower extremity was observed with a boot in place. The resident's left foot was observed placed directly on his bed without a boot. RN #1, who was also the Unit Manager and RN #2, who was identified as the Director of Nursing (DON) from a sister facility, were observed as they provided wound care for the resident. RN #1 removed the old dressing from the resident's (R) heel. The old dressing was observed with serous sanguineous (bloody) drainage. RN #1 described the wound in pertinent part as, "the wound is with yellow/white slough at the right side. It's a stage II pressure wound ...the left side of the wound is dark purple with a brown area...The wound is open ...It measures 1cm in length, 1.8 cm in width and 0.2cm in depth." Additional open areas were observed on the right foot and were brought to the RN's attention as RN #1 had not addressed them. At that time, RN #1 stated, "I saw him yesterday but I did not look at his toes ... I see the middle toes (right) has two dark red scabs ....The small toe has small purple discoloration ...There is an abrasion to the (R) large toe." The undocumented and previously unassessed areas on the resident's right foot were described by RN #1 as follows: -The front of the (R) middle toe had scab ...maroon in color 0.3X0.2 cm scab -The upper outer side of that same toe had a 0.2X0.2 cm maroon colored area. -The center front top of the (R) big toe had an open area that measured 0.2X0.6cm ...the small (R) little toe had a discoloration, (purple) area that measured 0.3x0.3 cm. A request was made to observe the resident's left (L) heel which was placed directly on the bed. The (L) heel was observed to be dark red unblanchable and boggy. RN #2 stated the resident's L heel "is dark red, unblanchable and boggy ...The left heel is boggy (indication of deep tissue injury), its dark red and non blanchable ...the area measures 4.0 x5.5 cm." The above pressure sores were undocumented and as of [DATE], the Director of Nurses (DON), MD and family were unaware of these findings. Although the CPO dated ,[DATE] (above) indicated that the resident's skin was to be checked daily, the resident's MARs and TARs dated ,[DATE] indicated no transcription of orders for daily skin checks and review of nursing documentation indicated no consistent daily skin checks for resident #25 as ordered by the physician. On [DATE] at 12:20 p.m., review of the resident's medical record revealed [REDACTED]. The findings above were brought to the attention of the DON on [DATE] at 12:25 p.m. Thereafter, a late entry nurses' note was documented addressing wound care and all wounds that were identified on [DATE] (see above). On [DATE] the physician and Medical Power of Attorney (MPOA) were notified of the wounds that were identified on [DATE]. The late entry notes dated [DATE] at 3:58 p.m., regarding resident #25's pressure sores read in pertinent part: "Location: Right 5th toe-purple intact discoloration ...Right 3rd toe proximal scab ...Right 3rd toe distal scab ... Right 5th toe area purple ...Right 3rd toe proximal area scab ...Right 3rd toe distal area scab ...right Heel, Stage II Left Heel, Stage I ...Measurements: Right 5th toe area: 0.3cm x 0.3cm Right 3rd toe proximal area: 0.3cm x 0.2cm Right 3rd toe distal area: 0.2cm x 0.2cm Right Heel 1cm x 1.8cm x 0.2cm, Stage II Left Heel 4cm x 5.5cm red, intact, boggy, non-blanchable Right great toe: a)Medial is 0.2cm x 0.3cm, b) distal 0.2cm x 0.6cm ...Right 5th toe = scabbed Right 3rd toe areas = scabbed Right Heel w/scant serous drainage. Wound bed dark red. Left Heel-red and intact ..XXX[DATE] (following facility notification during survey) the nurses' notes read in pertinent part, "MD and MPOA notified of new pressure area to left heel. New orders received." d. Staff Interviews On [DATE] at 1:30 p.m., RN#1 who was the unit manger was interviewed. -She stated, "He (resident #25) definitely had a wound to his R heel," on [DATE]," contrary to the skin assessment (see above) that indicated the resident's skin was intact (see weekly skin assessment dated [DATE]). -She further stated, "I would guess that he (resident #25) was not looked at (skin assessment not done)...you can't miss that open wound (wound to R heel)...unless you (had) not looked at the resident." On [DATE] at 1:33 p.m., the charge nurse reported that if a resident's wound got worse, she would notify MD, DON, and family then institute more pressure reduction devices. She reported if a new wound appeared she would measure, try to establish what happened, look at the wound, notify MD, DON, family, get orders, do risk management report (investigation report/incident report), and do immediate first aid if necessary. If risk factors were identified then she said she would make adjustments and if they were not identified, then she would try to identify the risk factors. She reported that she would not expect to see wound descriptions on the Skin Assessment forms unless it was new. She reported that the facility had recently initiated a 'Wound/Skin Healing Record' that should be used to give more thorough descriptions of the wounds. On [DATE] at 6:45 p.m., the DON was interviewed. -She acknowledged resident #25 had unidentified unstagable deep tissue damage to his (L) heel on [DATE]. The DON stated, "the boggy wound (to the L heel) was called by nurse as a stage I (wound) I would have called it (assessed wound) as unstagable deep tissue damage." -The DON stated, "My expectation it (pressure wound care) has to be noted in nurses' notes ...The physician should be notified (about new wounds and worsening wounds) on same day to get physician order [REDACTED]." On [DATE] at 6:48 p.m., the DON reported that she would expect all wounds to be described in terms of what the wound bed looked like, the odor, the drainage amount/type, and the skin around the wound and so on. She reported that the facility had forms for documenting the wound appearance and would expect the nursing staff to use them on all residents that had a wound. She reported that she would not expect the pressure ulcers to be documented on the Skin Assessment forms unless they were new. 2. Resident #39 Resident #39, a [AGE] year old male, was admitted to the facility on [DATE] with diagnoses, per face sheet, that included [MEDICAL CONDITION] (MS), dementia with behavioral disturbances, [MEDICAL CONDITIONS] bladder, [MEDICAL CONDITION], and dysphagia. a. Resident Status On [DATE] the Annual Minimum Data Set (MDS) documented that the resident was rarely understood and had short- and long-term memory problems. -He was totally dependent on staff with transfers, toileting, and bathing which required two persons assistance, locomotion on unit, eating which required assistance of one person. He required extensive assistance of two persons with bed mobility and dressing. -He required extensive assistance of one person with personal hygiene. -He had impaired functional limitation in range of motion to the upper and lower extremities. His primary mobility device was the wheelchair (w/c). -He had a pressure ulcer, open [MEDICAL CONDITION] on the foot, open [MEDICAL CONDITION] other than ulcers, rashes, and cuts. He had moisture associated skin damage. He had a pressure reducing device for the bed and w/c. He was on a turning/repositioning program, nutrition/hydration intervention to manage skin problems, and pressure ulcer care. Copies of care plans were obtained from the Director of Nursing (DON) on [DATE] at 2:30 p.m. Care plans revealed the resident had multiple risks for skin breakdown (and actual skin breakdown on [DATE]), including disease process (MS, [MEDICAL CONDITION]), functional immobility, cognitive impairment, incontinence and nutritional decline. Care plan review revealed: (1) The resident "is at risk for skin breakdown due to bowel incontinence and decreased mobility due to M.S. ([MEDICAL CONDITION]). Has Chronic Seborrhoeic [MEDICAL CONDITION] per Dermatology Skin sensitive due to mounding [DIAGNOSES REDACTED] per Senior Care review. At risk for pressure related altered skin, r/t (related to) immobility, hand splint, incontinence, contractures." "-[DATE] Small reddish bruise left hand 2.5 cm (centimeter) x 1.5 cm. -[DATE] Superficial area to LLE (left lower extremity) -[DATE] Four blisters to LLE. M.D. aware. Monitoring for "possible [DIAGNOSES REDACTED]" per M.D. -[DATE] Senior Care wound nurse assessed wounds. Right mid foot with stage II, 3.0 cm x 2.5 cm. (L)(left) thumb w/clear blister. (L) lateral leg blister at site of 4 (four) old blisters. -[DATE] Cut to middle toe, left foot from seat in footrest." Date Initiated: [DATE] Revision on: [DATE]. The interventions included the following: "-Abductor pillow between legs when in bed, wedge cushion behind back as tolerated. Date Initiated: [DATE] Revision on: [DATE] -Air mattress in bed with [MEDICATION NAME] pad. Date Initiated: [DATE] Revision on: [DATE] -Apply [MEDICATION NAME], moisture barrier, pat dry after each incontinent episode and baths per family request. Date Initiated: [DATE] Revision on: [DATE] -Apply foam in between fingers to reduce pressure. Date Initiated: [DATE] -Assist with ADL's (activities of daily living) to extent required to complete. Date Initiated: [DATE] Revision on: [DATE] -Bleach baths as ordered by M.D. Date Initiated: [DATE] -Call light in reach, answer promptly. Date Initiated: [DATE] -Carrot splint to right contracted hand. Date Initiated: [DATE] -Cleanse between skin folds with bathing and daily as needed. Date Initiated: [DATE] -Daily skin checks. Date Initiated: [DATE] -Encourage food and fluid completion. Date Initiated: [DATE] -Keep skin clean and dry. Date Initiated: [DATE] -Monitor affected areas to LLE outer calf [MEDICAL CONDITION] for s/sx of infection q shift until resolved. Date Initiated: [DATE] -Monitor area of redness to right leg for increasing redness or breakdown. Use loose stockings only. Date Initiated: [DATE] -Monitor deeper pigmentation of left buttocks daily. Cleanse sheering to bilateral inner buttocks with N.S.; cover with [MEDICATION NAME] q (every) 3 days. Date Initiated: [DATE] -Monitor for more blisters; if noted notify M.D. to r/o (rule out) [DIAGNOSES REDACTED]. Date Initiated: [DATE] -Monitor labs as ordered by M.D. Date Initiated: [DATE] -No briefs or plastics. Date Initiated: [DATE] -Notify family of any changes. Date Initiated: [DATE] -Notify M.D. and family of any skin breakdown. Date Initiated: [DATE] -Pressure relieving cushion while in w/c (wheelchair). Date Initiated: [DATE] -Prevalon boots as ordered to offload bilateral heels. Date Initiated: [DATE] Revision on: [DATE] -Rash to perineal, groin, buttocks areas; apply topical cream to areas as ordered. Date Initiated: [DATE] -Reposition every 2 (two) hours, use of wedge cushion behind back while on side as tolerated ... Date Initiated: [DATE] Revision on: [DATE] -Treatment to affected areas as ordered. See active physician orders. Date Initiated: [DATE] -Treatment to right mid (middle) foot as ordered. Notify M.D. of worsening skin condition... Date Initiated: [DATE] -Weekly documented skin assessments... Date Initiated: [DATE] Revision on: [DATE] (2) The resident "requires assist with toileting 2nd (secondary) to M.S. ([MEDICAL CONDITION]); bowel incontinent care required r/t (related to) inability to voice need to toilet for BM (bowel movement) associated with memory loss r/t (related to) dementia." Date Initiated: [DATE] Revision on: [DATE]. The interventions included the following: "...Define interventions to prevent skin breakdown from prolonged expose to urine and stool with checking and or toileting at least every ,[DATE] hours as needed, applying protective barrier after each incontinent episode and encouraging fluid intake ...Date Initiated: [DATE]" (3) The resident "has potential for altered intake d/t (due to) requires total assistance with food and fluid intake. Receives texture modified diet r/t (related to) dysphagia. At risk for skin breakdown." Date Initiated: [DATE] Revision on: [DATE]. The interventions included the following: "-Diet as ordered ... Date Initiated: [DATE] Revision on: [DATE] -...Encourage p.o. intake > (greater than) 75% of meals to meet estimated needs... Date Initiated: [DATE] -...Monitor weight per facility protocol, skin integrity, and labs when available. Date Initiated: [DATE] Revision on: [DATE] -Staff to offer/encourage fluids with and between meals. Date Initiated: [DATE] -Staff to provide total assistance w/meals at assisted dining table. Date Initiated: [DATE] Revision on: [DATE] -Supplement as ordered ..." Date Initiated: [DATE] Revision on: [DATE]. b. Failures after discovery of open areas - failure to assess the open areas and document assessments in a manner to monitor their on-going status QI Log: On [DATE] at 2:30 p.m., a copy of the Weekly Pressure Sore Quality Indicator (QI) Log was obtained from the DON and reviewed. The Weekly Pressure Sore QI Log documented the wound measurements by length by width by depth. This record was not kept in the resident's medical chart. The wound description was not documented on this form. The odor and drainage was documented as a yes or no. -[DATE]: right foot stage II: 3 cm (centimeter) by 2.5 cm by 0 cm. No documentation of location, odor or drainage or appearance (color of the wound bed and surrounding skin color) or documentation of pain related to the pressure ulcer. -[DATE]: right foot stage II: 2.5 cm by 3.5 cm by 0.1 cm. No documentation of location, odor or drainage or appearance (color of the wound bed and surrounding skin color) or documentation of pain related to the pressure ulcer. -[DATE] it read the wound was facility-acquired on [DATE]: right foot stage II: 2.5 cm by 3.7 cm by 0.1 cm. Yes was marked for odor and No for drainage. However, there was no documentation of location, appearance (color of the wound bed and surrounding skin color) or documentation of pain related to the pressure ulcer. -[DATE]: right foot stage II: 2 cm by 1.3 cm by 0.1 cm. No was marked for odor and No for drainage. However, there was no documentation of location, appearance (color of the wound bed and surrounding skin color) or documentation of pain related to the pressure ulcer. -[DATE]: right foot stage III: 1.6 cm by 1 cm by 0.4 cm. No was marked for odor and No for drainage. However, there was no documentation of location, appearance (color of the wound bed and surrounding skin color) or documentation of pain related to the pressure ulcer and no indication the physician was notified that the ulcer was now a stage III. -[DATE]: right foot stage III: 1.8 cm by 1.5 cm by 0.2 cm. No was marked for odor and No for drainage. However, there was no documentation of location, appearance (color of the wound bed and surrounding skin color) or documentation of pain related to the pressure ulcer. -[DATE]: right foot stage III: 1.5 cm by 1 cm by 0.1 cm. No was marked for odor and No for drainage. However, there was no documentation of location, appearance (color of the wound bed and surrounding skin color) or documentation of pain related to the pressure ulcer. On [DATE] (during survey) the Nursing Progress Notes documented, "Wound assessed today; measured and dressing changed per order. Rt (right) foot apply [MEDICATION NAME] Gel after cleaning with wound cleanser. Then apply Puracol, cover with bordered gauze